Leading with data on the path to normalcy

As we start building a path to normalcy, predicated on rolling out effective vaccination programs around the world, public and private sector leaders need real-time insights and actionable analyses to understand how we’re progressing against our goals. From forecasting disease hotspots to tracking vaccine uptake, the COVID-19 crisis has proven that data-informed thinking must be at the center of our response.
 
In our recent conversation with Sam Scarpino, we discussed the data-driven path to normalcy, including vaccination rollout, data that are fundamental for measuring success, and the complexities inherent in delivering on broad public health goals. The conversation was insightful, and inspiring. Leaning in with a data-first mindset, it’s clear that decision makers can face what lies ahead with confidence and redefine what it means to lead with data.
 
Tableau: COVID-19 has elevated the importance of data, and proven that we must have deep, actionable insights in order to navigate present and future challenges. How will data continue to play a critical role in this phase of the pandemic?
 
Sam Scarpino: As we enter the vaccine era of COVID-19, it’s important to reflect on and learn from our successes and failures. The same challenges—access, equity, supply, cost, etc.—we’ve faced with testing will also affect vaccination. And our failure to generate actionable, real-time data will hinder our ability to return to a new normal quickly. Simply put, we need much, much better data. Good data means we’re controlling COVID-19, because it comes from testing, tracing, and isolation. And data tells us what’s working, e.g., physical distancing and mask wearing, and what isn’t.
 
Tableau: As we look forward to vaccination rollout around the world, a 'return to normal' will look different geographically, and across timelines. What is your best description of what we should expect 'normal' to look like? Continued public health precautions for the foreseeable future, etc.?
 
Sam Scarpino: A new normal will mean that your chance of catching or transmitting COVID is low enough that it’s safe to visit elderly, or otherwise high-risk, family members and that we can safely and confidently chat with each other around the water coolers instead of over Zoom. But the process and time it will take to get there depends on how effectively we roll-out the vaccines and how effectively we leverage non-pharmaceutical interventions, i.e., physical distancing, testing, tracing, and isolation, to further reduce transmission.
 
Regarding vaccine rollout, the two most important variables are going to be: how much they reduce transmission and how quickly they are deployed. In the US, we’re already seeing a painfully slow and under-funded rollout and, internationally, the distribution is heavily biased towards high-income countries. More broadly, we are going to need passive, always-on surveillance for COVID-19 and for genomic variants, e.g., the B.1.1.7 variant from the UK you’ve seen in the news. Without these surveillance systems, we’re going to be continually caught off-guard by this disease and the “new normal” will feel a lot less normal.
 
Tableau: Given what we know about the vaccines that are receiving emergency authorization from the FDA, what do you see as the main factors and potential obstacles? What actions are necessary to support success?
 
Sam Scarpino: At this stage, the biggest obstacle is delivery of the vaccines. Given the lack of a uniform national plan, states and localities are creating their own distribution and vaccination plans. As a result, every state has a different approach, with varying levels of success[SS1] . As a result, we’re already seeing dreadfully slow uptake. What this means is that we need more federal support for community health organizations administering the vaccine and public health agencies monitoring and coordinating our responses.
 
Internationally, the recent authorization of the AstraZeneca-Oxford vaccine is a really big deal. Although—given its lower efficacy and potentially complex dose requirements—it’s far from perfect—this vaccine has a much greater chance for equitable distribution globally because low-and-middle income countries have guaranteed access and priority.  However, ensuring that low-and-middle income countries are vaccinated simultaneously with high income countries will be critical for both our global economy and equity.
 
Tableau: The speed of vaccine uptake is obviously a big unknown. What data do we need to watch, and at what level of granularity, so we understand whether we’re seeing the uptake we need? Can you explain the importance of community "zip-code level" data?
 
Sam Scarpino: There are two major concerns about uptake. First, how aggressively can we counter a well-organized and well-funded anti-vaccine movement? Will the global public health community receive the support it needs to educate the public about the safety of these vaccines and the rigorous evaluation process they have all gone through to ensure both efficacy and safety? Second—and this is the one we’re seeing make front-page news in the US—is how quickly we can actually deliver the vaccine and then inoculate individuals. As of this writing, the US has only given out 2.1M vaccines towards its December target of 20M. Although we fully expect things to improve, at this pace, it will take years for us to vaccinate enough individuals to reach herd immunity, where enough individuals have vaccine-derived immunity that the chance of a small outbreak growing large is very low.
 
Critically, we have to start doing right all of the things we've been doing wrong for the last year. The first step is a critical and realistic assessment of our failures and successes, which requires data.

Now, regarding the importance of community and zip-code-level data, one of the things we are historically bad at in the US is tracking vaccine uptake. If this pattern continues with COVID-19, we won’t have detailed enough data on which communities are close to herd-immunity and which are further away. Paired with our woefully inadequate and under-funded public health surveillance systems, we’ll be in the dark trying to respond to COVID-19 flare-ups. Combining all these, the result will be a long, slow, and painful return to any sense of normalcy. Not reaching a new-normal in time for the 4th of July will be tragic and is *preventable* but will require serious effort, funding, and coordination from the US federal government.
 
Tableau: How does ongoing COVID-19 testing play into the vaccine rollout phase?  Do you foresee availability of at-home, or more accurate rapid testing modalities in the next 6 months?
 
Sam Scarpino: We desperately need rapid, low/no-cost at-home testing. Slowly, we are seeing the FDA authorize the kind of low-cost, over-the-counter tests needed, but we have a long way to go over the next six months.
 
Both the models and the data from other countries like Vietnam and Australia have repeatedly shown that high-rates of testing, paired with isolation/quarantine and contact tracing/case investigation, can control COVID-19 even *without* a vaccine. Given how slowly we are deploying vaccines in the US and how important it’s going to be to continually monitor for COVID-19 flare-ups, we will need testing to get to a new normal faster and stay there. The real risk is that if we rely solely on the vaccines, it will be months or years before any true sense of normalcy returns. It will take that long to vaccinate enough individuals to reach herd-immunity, but, if we layer in other non-pharmaceutical interventions, we can get there in months!
 
Tableau: Is contact tracing still important now that vaccines are starting to be rolled out? How does contact tracing relate to two-dose vaccinations?
 
Sam Scarpino: Contact tracing is just as important now as it’s been since February. Even if we’re able to rapidly accelerate delivery of the vaccine, we’re still months and months away from vaccinating enough individuals to reach herd immunity. And getting to herd immunity, of course, assumes that the vaccines prevent transmission, not just symptomatic disease—something we won’t know for at least another month or more.
 
Contact tracing—and its vital partner, case investigation to determine the source of infections—remains our best tool for fighting this disease. We’ve seen myriad countries, like Japan, Thailand, Vietnam, Mongolia, China, South Korea, Taiwan, New Zealand, Australia, to name only a few, control this disease with testing, tracing, and isolation. In addition, the vaccines all require multiple doses, which means we need effective, and accurate systems, for monitoring uptake and ensuring individuals receive all the necessary rounds of inoculation. If our contact tracing systems aren’t working, we can’t control the disease and we can’t ensure individuals are being vaccinated properly.
 
Prior to COVID, the US was already dealing with deadly flare-ups of vaccine-preventable diseases like measles and whooping cough. As a result, we cannot and should not assume that relying on the vaccines alone will get us to a new normal.
 
Tableau: What do you see as the main phases of vaccine distribution, and what do we need to pay attention to along the way? Can you speak to any of the prioritization and equity considerations, and logistical issues related to distribution, especially how every state will classify and prioritize the "waiting list" differently, and what the actual experience will look like: is it likely to be a combination of private physician appointments, 'drive-through' vaccines, on-site via employer or school, or other?
 
Sam Scarpino: Right now, we’re all pretty much in phase 1 of vaccination, which prioritizes front-line health care workers and others likely to be in regular, direct contact with COVID-19 positive individuals. However, as I discussed above, we are vaccinating this group at a dreadfully slow pace.
 
As we start to expand the scope and scale of vaccination in the coming months, the ethical and logistical challenges will mount. For example, we know that communities of color and Native American populations have experienced an increased burden of COVID-19, as a direct result of generations of systemic racism that have impacted health and access to healthcare. As a country, and internationally, we need to engage with individuals in these communities to ensure they have a voice and vote in how vaccines are prioritized.
 
In the US, one of the hardest hit groups are individuals in jails and prisons. As a society, we have failed to protect individuals from additional cruel and unusual punishment due to COVID-19. And, regardless of your position on incarceration, we must all agree that none of these individuals were sentenced to COVID-19 infection.
 
Many persistent inequities have come to the fore-front of the COVID-19 vaccine rollout. As with racism and xenophobia, our lack of investment in public health, ongoing housing crises, and brittle, expensive healthcare systems will present huge barriers to efficiently and affordably vaccinating our citizens. And so, equity and access must be front-and-center in our vaccination plans. That means investing in drive-through testing and vaccination, no cost testing and vaccination, and ensuring we protect the most vulnerable in our society.
 
Tableau: What other key data points do you see as critical to enabling a speedy return to normalcy?
 
Sam Scarpino: Most of the tests we run in the US (and internationally) are focused on identifying COVID-19 positive individuals. This approach can be highly effective at controlling the epidemic (as we’ve seen in the countries listed above and at many colleges/universities across the US); however, these data don’t give an accurate picture of the true disease burden in the population. Think back to Stats 101 and the importance of random sampling when trying to estimate population-parameters without bias. Right now, we really don’t have a sense for how many people in each town have COVID nor what the chance is you’ll encounter someone with COVID if you walk into a restaurant and sit down. Without these numbers, we’ll struggle to determine whether the vaccine is interrupting transmission and, if so, by how much.
 
Without thoughtfully designed and well-funded COVID-19 surveillance testing, it will take us longer to determine whether, and by how much, the vaccines reduce transmission, and it will make it nearly impossible for the government, businesses, and the public to understand the true risk of infection in our populations. So, in addition to the kinds of genomic surveillance discussed above and granular, zip-code-by-zip-code-level data on vaccine uptake, we’re going to need regular population-level samples designed to estimate the current fraction of individuals infected with COVID-19 and the current fraction that has either recovered or been vaccinated. Without these data, the road to a new normal will be long and painful.
 
Tableau: What else have we learned about the importance of data from COVID-19 that can prepare us for when the next pandemic happens?
 
Sam Scarpino: Across the US, public health agencies are scrambling to replace legacy data systems, inter-state communication happens via fax machine, and records are still stored on pen/paper/excel. As a result, we were caught unaware by COVID-19 in the spring and ill-prepared to respond to summer and fall waves. Returning to normal from COVID, addressing persistent diseases like HIV/AIDS, TB, and antibiotic resistant bacteria, and preventing the next novel pathogen that finds itself in a crowded market from killing millions of people and upending our societies, we need better data and data systems for public health. Without them, a new normal may never come (or it will be a painful shadow of our pre-COVID lives). What we’ve seen over the past year is that society’s deepest challenges—from racism and its lasting effects, to chronically underfunding public health, or access to affordable healthcare and housing—largely dictated the course of this pandemic. We can build a brighter, safer, and more productive future. One that will help us return to normal faster and prevent this from happening again. But it’s going to take all of us, working together and it has to start now.
 
To learn more, watch Picture This: A Path to Normalcy.