Establish protocols to tighten controls rapidly in response to new outbreaks

Safeguard and Support Your Community

Jason Wang on establishing protocols to tighten controls rapidly in response to new outbreaks

Many Stanford Medicine experts have spent months focusing on how to consider, study and understand the procedures and protocols established to respond to new outbreaks of the virus and help restore the community. One such expert is Jason Wang, MD, PhD, associate professor of pediatrics and of medicine, who believes one of the most powerful tools at our disposal is research. Understanding the innate biology of the virus — how it’s transmitted, how the human body responds to its infection and how it can be stopped, among many other aspects — is a critical part of devising effective protocols that protect against COVID-19. Equally important is scientific collaboration: “COVID is actually one of those problems that is so big and cross-disciplinary it requires that we work together in a way that exemplifies team science,” he says.

COVID is actually one of those problems that is so big and cross-disciplinary it requires that we work together in a way that exemplifies team science

Looking forward, policymakers and community leaders need to be flexible: As the scientific community’s understanding of COVID-19 deepens, they must be ready to rapidly adapt public health and safety guidelines. And they must work to overcome the many challenges to implementing new strategies in a real and actionable way, such as resource procurement and the ability to share data swiftly and smoothly amid restrictive health care policies and laws. Wang explains more below.

At the beginning of the pandemic, how did you think about establishing different protocols in response to the viral outbreak?

Wang: When establishing any sort of viral protocol, you first have to understand as much about the biology of the virus as possible — the science of its transmission. And because this coronavirus is so new, we initially based that on our prior experiences with other coronaviruses. For example, early on, many people believed that transmission occurred through droplets and that it wasn’t necessary to wear masks. But as our knowledge of the virus increased, we realized that it could also infect via aerosol spread, in which case wearing a mask became crucial. We’re constantly reminded to be humble when dealing with a new virus, and when evidence changes, we also have to change what we practice. And once new information comes to light, it’s critical to disseminate it quickly so that members of the committee — and eventually community — know that a change is in order.

In terms of trying to make various protocols meet the needs of the community, it’s best to have established a task force, composed of frontline health care providers; researchers studying the virus; public health experts; and other key community stakeholders, such as school superintendents, parents, teachers and staff. But having the task force is not really sufficient to carry out the protocol — what you really need is a command center to operationalize those protocols. The command center’s role is to facilitate these guidelines in real life. When you suggest something in the protocol, people need to be able to act on it. So when you say wear masks, people need to be able to either buy masks or make their own masks. When you suggest that people should get tested, there needs to be adequate testing available. When you want to initiate contact tracing, you need to have the right tools to do it. And so often what that means is setting up operationalized systems that account for data collection, supplies of masks or supplies of testing reagents, and so forth. This virus is testing our health system to see how quickly we can respond to a threat. And we’ve learned a lot from this particular pandemic.

Where would you say the community protocols, and the operationalization of them, stand today?

Wang: A very popular topic is how to reopen schools. Let’s look at testing in terms of the logistics and operations that would need to be enacted for this to happen. Approximately 6.2 million children are in school in California. If you want to test every kid every week, that’s 6.2 million tests per week. But if you look at how many tests are being performed in the state of California today, there’s a large gap. And the cost of the test today is still quite expensive — in the range of $50 to $200 for a RT-PCR test. Once new antigen tests are introduced, the price could drop to $5 to $10 per test, which is more manageable, but could still add up. And that’s prohibitive.

Outside of cost, you have to look at the resources and ask if we even have the supplies necessary to do this. Do we have a data system to inform which students should stay home and which students should go to school? And once a child tests positive, is there an established quarantine protocol? And can we make sure that person is actually at home? So it’s not just a matter of policy. Often when people talk about what should be done, they talk about it a 35,000-foot level, rather than thinking about how to ground the policy realistically, adapt as parameters around the virus change and operationalize it. Unless we do that, we’re going to meet obstacles everywhere.

Where do we go from here?

Wang: Much of this is understanding our resources and how we get them to the point of care. I would say that when you’re trying to solve or understand a problem you should start with a comprehensive checklist that lays out all the components necessary to accomplish whatever it is you’ve set out to do. Take testing, for example. When you’re developing a checklist, you might say, “If I’m going to develop this rapid test that’s going to be $5 per test, what are the key materials needed? Who’s making them? Where do we source them? How long does it take to produce 1 million tests per day? Would that translate to 7 million per week?”

It’s a matter of fundamentally understanding what it would take to bring it to a reality, including details of what it takes to bring prices down and share data across systems. It can’t be done in silos either. We’re in a war against the virus, and the virus is spreading very, very quickly. If we act under business-as-usual terms, we won’t be able to win.

As we look to the next several months, are there specific research areas that should be a focus as we continue to develop and inform new protocols?

Wang: There are so many different research areas that we still need to develop or better establish. We’re still understanding the nature of the disease and its biology, the best ways to test and disseminate testing — including new work here at Stanford involving pooled testing — and across the country there are numerous clinical trials testing treatment efficacy. Beyond that, we’re still investigating vaccines, the possibility of non-pharmaceutical interventions, contact tracing, improving telehealth and much more. In my group, we try to keep up with the literature daily. The great thing about Stanford is that a lot of investigators are working on issues of COVID-19 and we can share information very quickly.

How do you think stakeholders, either at Stanford or outside of Stanford, can get involved in the development of guidelines and protocols, or the operationalization of those protocols?

Wang: The best thing to do is really to involve people from the community and to tell them why these kinds of protocols are necessary. The stakeholders we involve — such as public health or city leaders — can speak to other members of their circles and disseminate information, and in that way inform our broader community about what we’re working on here at Stanford. The idea is that when a health order is issued from a county like Santa Clara County, people will have a better understanding about the process of how that came to be — that the decision has undergone thorough stakeholder involvement and input.

We’ve also been so fortunate to have benefited from an enormous amount of philanthropy that’s come in from our surrounding communities to support our research. Philanthropic donors have met the urgency of this situation, supporting scientists in their need to quickly grow and develop research ideas, which has been incredibly helpful.

Jason Wang, MD, PhD
Associate Professor of Pediatrics and Medicine