From Health Disparities to Hotspots to Public Health Strategies: The Impact of the COVID-19 Pandemic in North Carolina

Epidemiology and Health Disparities

Early data from the Centers for Disease Control and Prevention (CDC) identified the most vulnerable groups for COVID-19 as persons with underlying medical conditions (i.e., cardiovascular disease, diabetes, chronic lung disease), and older adults, with a startling death rate of 902/100,000 among persons aged ³ 80 years [3]. In comparison, the overall US death rate from SARS-CoV-2 infection was 64/100,000 as of October 10, 2020 [1]. The reported death rate in North Carolina was lower than the national rate at 35/100,000; however, 81% of deaths have been among people aged ³ 65 [2]. Nationwide, persons aged 20–29 years accounted for > 20% of all SARS-CoV-2 infections during June–August 2020 [4]. In North Carolina, persons aged 18-24 represent 16% of all cases, with individuals aged 25-49 representing 40% of cases and 4% of deaths [2].

National surveillance data revealed the health disparities in COVID-19 associated with race/ethnicity of persons affected and area of residence. Compared to non-Hispanic whites, non-Hispanic Blacks had 2.6 times the risk for SARS-CoV-2 infection and 4.7 times the risk of being hospitalized [5]; Hispanic/Latino persons had 2.8 times higher risk for infection and 4.6 times higher risk for hospitalization from COVID-19 [5]. Using cumulative county-level data collected during February–June 2020, the CDC identified US counties that were “hotspots,” based on algorithmic thresholds related to the number of new cases and the changes in incidence [6]. Among all 18 hotspot counties identified in North Carolina, health disparities in COVID-19-associated mortality were notable among Hispanics in each area [6].

The impact of health disparities on COVID-19 incidence is summarized by Dr. Corbie-Smith and colleagues in this issue [7]. They note that Black and Latino individuals are overrepresented in COVID-19 deaths in North Carolina, and that this is likely a result of inequities in housing, transportation, food access, and educational opportunity. Importantly, the authors provide several opportunities for reducing these disparities. In this issue, George Hendrix further discusses the impact of COVID-19 on the Hispanic and Latino community in the state, and notes that their barriers to health care include language and the fact that some are migrant workers [8]. He notes that a grassroots approach is critical to addressing health disparities in these groups.

During a six-week period from June to mid-July 2020, the North Carolina Department of Health and Human Services (NCDHHS) reported a 183% increase in the incidence of COVID-19, from 7 to 19 per 100,000 persons per day [9]. However, differences between counties throughout the state are evident based on the COVID-19 Pandemic Vulnerability Index (PVI), which is calculated from key indicators including infection rates, baseline population concentration, current interventions, and health and environmental vulnerabilities (e.g., age distribution, health disparities, and hospital beds) [10 {preprint}]. Several North Carolina counties are in the top 100 counties with the highest PVI scores nationwide. One rural county located in Eastern North Carolina had a reported death rate of nearly 140/100,000 [11].

In a commentary that appears in this issue, Dr. Pettigrew identifies potential contributors to the vulnerability of some of our counties facing COVID-19 challenges, including racism, lack of universal health care access and workers’ protections, and defunded public health infrastructure [12]. Dr. Gerald also notes the specific impact of this pandemic on rural communities and provides recommendations for reducing health disparities [13].

Viral Transmission

North Carolina has some of the top scientists in the world conducting research on SARS-CoV-2. The virus has ribonucleic acid (RNA) as its genetic material, and is covered by a large number of “spike” (S) proteins on its surface that bind to specific receptors (angiotensin-converting enzyme 2 receptors), allowing the virus to enter cells in the lungs and other organs; these S proteins serve as targets for some diagnostic assays and future vaccines [14]. The virus is zoonotic, probably originating from bats with spread to humans, although the range of other mammals that can become infected remains unknown. SARS-CoV-2 has been demonstrated to spread from humans to other animals. NCDHHS reported the first dog in the state with laboratory-confirmed SARS-CoV-2 infection in August, but transmission from pets or livestock to humans appears rare [15].

SARS-CoV-2 is primarily transmitted through droplet transmission between persons within a short range (e.g., less than six feet), similar to other respiratory viruses (Table 1). The period of infectivity among most otherwise healthy people without immunosuppression is up to 10 days [16]; among immunocompromised or hospitalized patients, the period of infectivity may be up to 20 days. In addition, an infected person may be infectious starting from 48 hours (or two days) before symptoms or testing positive for COVID-19 [16]. Furthermore, a significant proportion of persons with COVID-19 (estimated 40%-45%) may have subclinical or no symptoms and still transmit the virus [17].

The CDC has acknowledged the potential for airborne transmission of SARS-CoV-2, based on a few well-documented examples that occurred under special circumstances [18]. These circumstances involved enclosed spaces, prolonged exposure to respiratory particles that were generated with expiratory exertion (e.g., shouting, singing, exercising), and inadequate ventilation or air handling. The virus has been shown to remain viable in closed conditions for up to three hours and on certain surfaces for up to 72 hours [19] (Table 1), underscoring the need for frequent disinfection of potentially contaminated surfaces or shared objects with an EPA-approved disinfectant. Like similar enveloped viruses, SARS-CoV-2 is inactivated by 60%-90% alcohol-containing hand antiseptics within 15 seconds [20].

Transmission of SARS-CoV-2 infections is highest among close contacts (defined as individuals who have been within six feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) [16]. Among households with a laboratory-confirmed COVID-19 case, the overall secondary attack rate (defined as the probability that an infected individual will transmit the disease to uninfected persons) is estimated to be 18.8% [21 {preprint}], emphasizing the importance of education about home isolation for persons with mild SARS-CoV-2 infections. Persons with COVID-19 can generally discontinue isolation 10 days after symptom onset and after 24 hours with no fever, without the use of fever-reducing medications, and with improvement of other symptoms [22].

Testing and Surveillance

Over 3 million tests for SARS-CoV-2 have been conducted in North Carolina to date, based on patient-level and aggregate data submitted electronically through the NC COVID-19 Surveillance System (NC COVID) and COVID-19 Aggregate Test Reporting (eCATR) [2]. The overall positivity rate was 6.3% as of October 15, 2020 [2].

Local health departments have conducted most of the case investigations in the state after notification of cases in the North Carolina Electronic Disease Surveillance System (NC EDSS), which involves collection of information including symptom onset, source of illness, activities during the case’s infectious period, and list of potentially exposed contacts. Surveillance data are updated weekly on the COVID-19 Dashboard [2], which also houses data regarding number of hospitalizations and cases diagnosed at North Carolina hospitals. In this issue, Dr. Sickbert-Bennett and Lauren DiBiase describe in detail all the sources of COVID-19 surveillance in North Carolina and provide recommendations for improvements to our current surveillance system [23].

Under the national declaration of a public health emergency due to COVID-19, the United States Food and Drug Administration (FDA) has approved more than 200 diagnostic and antibody tests for SARS-CoV-2 detection under an Emergency Use Authorization (EUA) [24]. Several tests using polymerase chain reaction (PCR) assays that can detect the virus’s genetic material from respiratory specimens collected by either health care professionals or through self-collection in clinics or at home have been authorized for diagnosis of SARS-CoV-2; newer PCR-based tests using saliva as a specimen have also been authorized [24]. Furthermore, SARS-CoV-2 rapid antigen tests that have received EUAs can quickly detect fragments of proteins found on or within the virus by testing swabs collected from the nasal cavity, although antigen tests have substantially lower sensitivity.

Diagnostic testing for SARS-CoV-2 is recommended for persons with symptoms of COVID-19 and for close contacts irrespective of symptoms. Some experts recommend that close contacts wait at least 5 days after last known exposure before testing; however, it is important to note that a negative test following an exposure to a person with COVID-19 does not exclude infection if the contact is still within the 14-day incubation period. Testing is also recommended for individuals with higher risk of exposure or a higher risk of severe disease if they become infected, regardless of symptoms (e.g., health care personnel, first responders, and people in long-term care facilities, homeless shelters, and correctional facilities) [25].

Other tests using blood samples have received EUAs for the qualitative detection of antibodies to SARS-CoV-2. Antibodies are generally detectable 1-3 weeks after symptom onset, indicating the development of an adaptive immune response [26]. It is still unknown whether and to what degree an antibody response indicates immunity to future infection, and reinfection with SARS-CoV-2 has been reported in a small number of persons [27]. A study conducted in North Carolina that enrolled outpatients and inpatients across a health system representing 267 different zip codes identified a low prevalence of 0.8% for SARS-CoV-2 based on antibody testing during late April through June [28]. A nationwide study reported that fewer than 10% of the adult population developed antibodies against SARS-CoV-2 during the first wave of the pandemic [29].

Clinical Management

The National Institutes of Health (NIH) created clinical criteria for defining the severity of illness from COVID-19, which have been useful in identifying appropriate therapies for individual patients (Table 2) [30]. Mild to moderate pulmonary disease occurs in the majority (81%) of persons with symptomatic COVID-19. However, persons with severe to critical illness from SARS-CoV-2 can develop cardiac, hepatic, renal, hematological, neurological, and other complications (e.g., thromboembolic events). In North Carolina, an estimated 51.1% of adults are at higher risk for severe COVID-19 illness based on age ³ 65 years, having at least one underlying health condition, or both [2]. Multisystem inflammatory syndrome in children (MIS-C) and adults (MIS-A) can also result in multiorgan involvement [31]; as of October 10, 2020, there have been 43 cases of MIS-C reported in North Carolina [2]. In this issue, Dr. Rolfe and coauthors describe the frequency and numerous long-term sequalae of SARS-COV-2 infection observed among patients [32]. Importantly, persistent symptoms are common and may occur even among symptomatic patients who were never hospitalized.

The NIH has also issued COVID-19 treatment guidelines for patients depending on the severity of illness, based on scientific data and review from an expert panel that includes members from North Carolina academic institutions [28]. For mild to moderate illness from COVID-19, there are no specific therapies for persons managed at home that have been formally recommended at this time. For hospitalized patients, the FDA recently approved remdesivir, an intravenous antiviral agent with activity against SARS-CoV-2, for use in adult and pediatric patients aged 12 and older and weighing at least 40 kilograms (about 88 pounds); younger children may be provided remdesivir under an EUA [33]. The NIH COVID-19 treatment guidelines also recommend the use of dexamethasone as an anti-inflammatory agent for hospitalized patients requiring supplemental oxygen and those with severe or critical illness [30]. Other therapies for SARS-CoV-2 infections, including convalescent plasma and monoclonal antibodies (specific proteins that are made to decrease the virus’s ability to make more copies), are being investigated through clinical trials in North Carolina and across the country. It should be noted that there is no recommended pre- or post-exposure therapy for SARS-CoV-2.

Contact Tracing

Contact tracing is an important public health strategy for COVID-19 in order to identify people who have recently been in close contact with someone who is infected, allow rapid notification for testing, and provide support for necessary resources if the contact becomes symptomatic [16]. The CDC has supported and led a nationwide, coordinated training effort to build a public health COVID-19 contact-tracing workforce, and has responded to requests for assistance from hotspot counties in the United States. In June 2020, the CDC and the US Public Health Service (USPHS) deployed multidisciplinary teams to North Carolina to assist with case investigation, contact tracing, and data management; the CDC Foundation also provided additional contact tracers to support local health departments in the state to manage these hotspots [34].

In addition to traditional contact tracing procedures, digital contact tracing tools like SlowCOVIDNC are now being utilized by public health to enhance efforts during this pandemic. SlowCOVIDNC uses Bluetooth technology to let users anonymously share a positive COVID-19 test result through an app, which can notify other users who may be close contacts [2]. NCDHHS is also using a COVID-19 Community Team Outreach (CCTO) Tool, which provides a platform to manage cases and contacts, perform digital outreach, and store data in a central repository. CCTO provides local health departments access to contact-tracing data collected by other organizations during outbreak or cluster investigations [2].

Impact on our Communities

Since March 2020, numerous outbreaks or clusters of SARS-CoV-2 have been reported in North Carolina in congregate living facilities, such as long-term residential care and correctional facilities [2]. In this issue, Dr. Boucher notes the increased health complications and financial stressors for recipients of long-term care services and their caregivers, which contribute negatively to quality of care and often lead to social isolation [35]. He also provides recommendations for decreasing social isolation.

Child care programs have also been significantly affected by COVID-19 in the state, and Michelle Rivest reports 384 COVID-19 child care clusters in North Carolina in this issue [36]. School-related closures have been widespread, and in this issue Dr. Boutzoukas and coauthors also note the impact of the COVID-19 pandemic on children, including decreased academic achievement and heightened food insecurity as a result of K-12 school closures [37]. Lastly, several universities in North Carolina also experienced clusters of COVID-19 cases among undergraduate students despite extensive planning for reopening this fall [38], prompting a shift from in-person classes to online-only virtual learning at most institutions, which may affect the quality of higher education among young people in our state.

Public Health Strategies

In response to this pandemic, North Carolina’s strategy has involved a phased reopening of sectors/activities to minimize spread of SARS-CoV-2, and requirement of masks or face coverings in public locations (indoors and outdoors) when physical distancing of six feet is not possible. On May 8, 2020, North Carolina began “phase 1” of easing COVID-19 restrictions to help revive the economy while protecting public health. Based on the number of positive tests and hospitalizations for SARS-CoV-2 statewide, the state entered “phase 3” on October 2, 2020, which expanded outdoor venues for bars, movie theaters, and other entertainment venues to 30% capacity. Public school districts and charter schools can choose to implement different operational plans for elementary schools (grades K-5), which involve use of masks and various approaches to physical distancing in classrooms and during other school activities [2].

Public health initiatives conducted at the local level will continue to be critical in the response to rapid increases in cases and clusters, and to improve access to testing and outreach among our communities. In this issue, Dr. Pease and coauthors describe the strategy used by one county health department in the state to curb the spread of COVID-19 in congregate living facilities, including the use of a strike team to rapidly assess and control outbreaks [39]. Dr. Fiscus and coauthors also report in this issue on how mobile testing units rapidly established by health systems across North Carolina can provide underserved residents critical access to diagnostics and care [40].

The COVID-19 pandemic continues to take a large toll in North Carolina and across the United States. As we face the uncertainties of a new year with COVID-19, our medical and public health community will need to remain steadfast in our messaging to the public, especially as vaccines become widely available for SARS-CoV-2. In this issue, Dr. Sturgill emphasizes the importance of consistent and accurate public health messaging and patient education, based on scientific and evidence-based resources [41].