The Medical Lab Professionals Studying COVID-19 in Seattle, Washington
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Note from the editor: One of our writers, Bree Nicolello, has been “sheltering in place” in Seattle, Washington for more than two weeks and is helping Americans across the country access much-needed resources (personal protective gear, unemployment claims, loans, etc). She has been tracking the spread of the disease within her community and participated in a phone conference with the state’s foremost professionals who are on the front lines. Here’s what she’s learned.
As of March 30, 2020, the United States now has over 122,654 cases of COVID-19—presumptive and confirmed—more than any other nation. Over 2,000 Americans have died and figures are rising across the country. Medically known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this highly infectious strain was originally discovered in Wuhan, China in November 2019. It has now become a global pandemic impacting over 100 countries across the globe.
The virus is naturally-occurring and spreads when infected individuals are within close contact, or less than six feet, of one another. It can also spread when an infected person coughs or sneezes. Some areas now have community transmission, where individuals can get sick without coming into direct contact with an infected individual. For example, a non-infected person may come into contact with a surface that has the virus on it and then touch their face. This is why social distancing, or staying more than six feet apart, and constant hand washing is a vital part of combating the virus.
The first case in the United States was discovered in Everett, Washington on January 21, 2020. The home of Boeing, Everett is a smaller city just thirty minutes north of Seattle and part of a metropolitan area of almost four million people. The United States’s patient zero is a thirty-five-year-old man who had recently returned from Wuhan, China via Seattle-Tacoma airport. A mere four days after returning to the country, he went to an urgent care clinic and reported pneumonia symptoms. The next day, he was transferred to Everett’s Providence Regional Health Center.
Few people, with the exclusion of epidemiologists and medical scientists, were ready for what would come next.
Early Signs of a Pandemic
Dr. Tyler Bedford is a computational biologist at Fred Hutch specializing in rapid spread and evolution of viruses. He posted an update to his blog on January 31, 2020. He had been tracking the spread of the virus in Wuhan and studying the genome, or genetic sequence, of the virus. His blog included the following paragraph:
The conclusion of sustained human-to-human spread became difficult to ignore on Jan 17 when nCoV [COVID-19] genomes from the two Thai travel cases that reported no market exposure showed the same limited genetic diversity. This genomic data represented one of the first and strongest indications of sustained epidemic spread.
At that time, the World Health Organization was emphasizing that the virus only spread through limited human-to-human contact. Meanwhile, Bedford was analyzing the data that Chinese researchers had uploaded to GISAID.org, a worldwide epidemiological database. Researchers had uploaded genomes from five different cases, each with limited genetic diversity across genomes, meaning they were likely the same virus. If the case was only spread through limited human-to-human contact, then why did the genomes from the two Thai travel cases look so similar, despite no interaction with infected individuals?
Bedford reached a chilling conclusion: “As this became clear to me, I spent the week of Jan 20 [January 20, 2020] alerting every public health official I know.” The virus was likely the beginning of a global health emergency.
The Beginning of a National Health Crisis in the U.S.
In February, a resident of the Life Care Nursing Home in Kirkland, Washington showed COVID-19 symptoms and was transferred to Harborview Medical Center. A limited number of tests were available in the United States but healthcare professionals managed to secure a test for her. She tested positive. On February 24 and 26, two more deaths at Life Care Nursing Home were reported. Both would test positive for the disease.
At the same time, a high school student in Everett tested positive. A post office worker in nearby Federal Way, Washington tested positive. On February 29, Washington reported the death of a man in his 50s who had no interaction with any infected individuals. It confirmed that the virus was spreading throughout the Seattle-Tacoma-Bellevue metropolitan area and had likely been doing so for weeks. Washington became the epicenter of the outbreak with dozens of deaths and hundreds of cases, only to be surpassed by New York in the last week—a state with almost double Washington’s population.
Since the initial infection of fifteen Americans in February, over 85,000 confirmed and presumptive cases have been reported to the Centers for Disease Control (CDC) as of March 27, 2020. In just a month, the virus spread to all 50 states and each territory.
However, experts think the real number of cases is likely much higher. Testing is highly restricted and only available to a limited number of people. Faced with an inability to test and understand the true spread of the disease, local and state governments are urging residents to shut down all non-essential travel and activities. In other words, assume everyone is infected and take every precaution necessary to “flatten the curve,” ensuring that the spread is slowed down to a pace that healthcare professionals can reasonably test and treat.
At this point, there is a national shortage of tests and is one reason why the virus has spread so rapidly. Instead of a national commitment to immediately deploy testing and enact emergency social distancing measures to limit the impact of the virus, local and state governments are racing to implement testing and “shelter in place” requirements with little resources and guidance.
The CDC lost valuable time by sending out test kits that had a non-functioning ingredient. The Food and Drug Administration (FDA) delayed labs that were manufacturing their own tests. In the meantime, the virus was spreading, doubling, and growing while medical scientists were left with hundreds of samples that they were not allowed to test.
By the time Washington reported their first death attributed to the community spread of COVID-19, just 472 people had been tested.
The University of Washington Tracking the Spread of COVID-19
The University of Washington is just under three miles away from Fred Hutch. Frequent collaborators, the University of Washington is home to some of the most-respected medical programs and research clinics in the world.
Although just two years old, the Seattle Flu Study has already recruited thousands of volunteers to take at home samples and send them in for evaluation. This information is then used to “detect, monitor, and control outbreaks” across Seattle.
Dr. Helen Chu is an infectious diseases specialist at the University of Washington and a co-leader of the Seattle Flu Study. In January, her team was monitoring the outbreak in Wuhan and realized the virus had a strong likelihood of spreading in the United States. The Seattle Flu Study reached out to the federal government to see if they could reconfigure their tests to include COVID-19. The federal government denied their request, stating her team received funding to only test for the flu—not COVID-19.
Starting on February 25, Dr. Chu and her team went ahead and tested the samples that hundreds of Seattle residents had sent in. State regulators at the Washington State Department of Health told her to stop testing altogether, while the CDC and the FDA threatened her with a cease and desist order. Confident that this ethical shift was in the larger public interest, Dr. Chu and her team defied the state and federal government and continued to test samples.
Within days, they had a positive test: the high school student in Everett. They immediately sequenced the genome, posting their results to the same database that Bedford was using: GISAID.org.
The sequence was then shared on NextStrain, which Bedford co-founded, and compared to similar genetic sequences around the globe. It matched that of patient zero, the man who traveled from Wuhan to Seattle just a few weeks prior. During that time, it had circulated throughout the community for six weeks.
On February 29, Bedford confirmed that the virus had already reached Seattle and the State of Washington. It was only a matter of time before it spread throughout the entire United States.
Battling the Pandemic in Seattle, WA
As of late March, there is still limited access to COVID-19 tests, as well as needed medical equipment. Distilleries in Seattle are switching from making vodka to hand sanitizer. Furniture makers and seamstresses are transitioning operations to manufacturing and sewing masks. Healthcare professionals are working 60- to 80-hour weeks, conducting telemedicine visits and setting up mobile testing sites. However, widespread testing remains unlikely. Even now, mobile testing sites are only available to those who meet certain criteria and receive an appointment.
Throughout the month of March, local governments and the state of Washington began implementing measures to protect the community and require social distance. Things have changed hour-to-hour within the State of Washington. Everyone was advised to work from home. If anyone showed symptoms, they were required to quarantine at home for 14 days. With such limited healthcare capacity and testing, healthcare providers would only accept and test those in need of critical medical assistance.
But then a harsh reality set in: COVID-19 is not always symptomatic, particularly in young and healthy people. Without the capacity for widespread testing, it is likely that asymptomatic people are unknowingly spreading the virus—putting elderly, pregnant, and/or immuno-compromised people at severe risk.
Washington immediately took unprecedented action to stop the community spread. Governor Jay Inslee banned gatherings over 250, including concerts and large weddings. He then banned non-essential gatherings under 250. Within a week, state schools were to be moved online for a month. Then restaurants and bars were closed and only permitted to offer takeout or delivery. On March 24, 2020—just two months after the first case appeared—Governor Inslee issued a stay-at-home order, requiring residents to shelter in place until mid-April.
With COVID-19 having spread throughout the country, there is now a shortage of protective supplies and tests. Jerrod David, Assistant Secretary for Disease Control and Health Statistics at the Department of Health, emphasized that the Department’s top priority is to “procure materials we need.” This includes ventilators, gloves, surgical masks, N95 masks, gowns, and disposable stethoscopes—collectively known as personal protective equipment (PPE). “There is global demand. Whatever we bring is not enough to satisfy the need in the community,” he stated. “We determine who gets materials based on a public health approach.”
This means materials are being distributed based on which patients and frontline professionals are most at risk, including nursing home and long-term care facility residents and professionals and healthcare workers. “Unfortunately, we can’t fill needs even in that ‘Tier 1’ category.”
In response to questions asked at a March 26 press briefing—a phone call I participated in with local and national media outlets about how the State of Washington planned to provide PPE to patients and healthcare providers—Linda Kent, Director of Public Affairs at the Washington Department of Enterprise Services, echoed David’s concerns: “Multiple agencies are working to provide hand sanitizer, disinfecting equipment, wipers, and PPE.”
Some agencies, such as the Washington Department of Commerce, are working with manufacturers to switch production to needed materials and equipment. Others are working with federal resources, such as the Strategic National Stockpile. “We need as many items in the door as quickly as possible. We’re in this for the long haul,” Kent said.
The Department of Enterprise Services handles purchasing for Washington state, including materials desperately needed by hospitals and clinics to combat the spread of COVID-19. They handle distributing materials to “local emergency divisions in Washington, so [materials] get to where they need to go.” They handle the physical delivery, working to get protective personal equipment out to healthcare facilities around the state. The biggest challenges? “Gowns, sanitizers, and test kits.”
The Race for a Vaccine: A View from Early Spring 2020
Public health officials say it’s unlikely for COVID-19 testing to become widespread. Instead, the focus is shifting to finding a vaccine that can greatly reduce the spread of the virus.
Kaiser Permanente began accepting volunteers for a trial on March 23, where they can be the first human subjects to receive a vaccine for COVID-19. The result of a partnership between Moderna, a biotechnology company specializing in RNA and the National Institutes of Health, the vaccine will not be available until a year or two from now.
However, medical scientists hope it could be used for emergency situations, such as high-risk populations or frontline healthcare workers. However, this method of producing a vaccine is untested and may not work. Should this approach work, it would be an enormous scientific discovery in the field of immunization.
Perhaps more tried and true, Dr. David Spiegel, a professor of pharmacology and chemistry at Yale University, and Atlantic staff writer Graeme Wood emphasize the “human blood bag” approach. Tens of thousands of people already have survived COVID-19, meaning their body has fought the disease and won. This also means their body is now producing antibodies, which can be filtered out of their blood and used to produce a serum called hyperimmune globulin. This serum is not a clear path to victory: antibodies may only last for a few weeks or months, not to mention antibodies have a small chance of making someone sicker. (The rare occasion of this happening is with dengue fever.)
However, medical scientists at John Hopkins University received approval from the FDA to go ahead with this method. History is on their side; this approach was used to successfully treat the ebola virus in 2013.
All of this said, time is still of the essence. The longer the world goes without a vaccine and in many cases, access to testing, the risk of death or serious long-term impacts increases. China was able to greatly decrease the spread of COVID-19 when they implemented rigorous social distancing measures after only 500 reported cases and 17 deaths. South Korea and Taiwan have made testing available on a widespread, national scale—and did so within weeks of China announcing their first cases.
A National Crossroads
Seattle may again prove to be a leader in modeling the safest response to COVID-19.
On March 23, the Seattle Flu Study partnered with Seattle and King County Public Health, Fred Hutch, University of Washington Medicine, Seattle Children’s Hospital, and the Brotman Baty Institute to launch the Greater Seattle Coronavirus Assessment Network (SCAN). Building off of the work that Dr. Chu and her team did in the early weeks of the pandemic, SCAN will analyze samples from sick and healthy people to understand the impacts of COVID-19. People will send in samples from home, which Amazon will pick up and drop off. Just like their work with the flu study, researchers will use this data to monitor and understand the outbreak.
It is likely that a COVID-19 vaccine will be found eventually. In the meantime, following CDC social distancing and testing guidelines is the most important way to stop the spread of this disease.
