Dean's COVID-19 Commentary

Colorado’s pandemic picture remains mixed, without a clear trend for the epidemic curve. Hospitalizations have risen over the last two weeks, reaching 185 for the week of October 4. Test positivity has plateaued at about 5.5% while the aggregated wastewater virus concentration for the state is dropping. We have released a new modeling report showing projections with and without the arrival of a new variant. Not surprisingly, a hypothetical new variant with greater immune escape than current Omicron subvariants and with high virulence, could send the epidemic curve up sharply. New subvariants of Omicron continue to emerge. Whether one or more of them has the characteristics needed to reignite the pandemic is not clear. The report provides a scan of the subvariants that are currently lurking.  

Perhaps, we are experiencing a transition from epidemic to endemic, defined in CDC course material as:
 
“The amount of a particular disease that is usually present in a community is referred to as the baseline or endemic level of the disease. This level is not necessarily the desired level, which may in fact be zero, but rather is the observed level. In the absence of intervention and assuming that the level is not high enough to deplete the pool of susceptible persons, the disease may continue to occur at this level indefinitely. Thus, the baseline level is often regarded as the expected level of the disease.”

This and other definitions do not offer quantitative criteria for identifying the epidemic to endemic transition. In my opinion, it is too early to declare that the pandemic has become endemic. The modeling shows that an aggressive and virulent variant could quickly change the COVID-19 situation. There are recent reports in Science and Nature that are replete with (interesting) speculation about variants and the winter ahead.  

With the mid-term elections a month away, there is an ongoing barrage of political messages on the airways. There is also a new and equally omnipresent tsunami of advertisements from lawyers recruiting people who may be eligible for compensatory damages related to having lived at Camp Lejeune in North Carolina, a Marine Corps training base. To find examples, search “Camp Lejeune settlements” in Google. These advertisements reflect a new chapter in the long story of drinking water at Camp Lejeune contaminated by trichlorethylene (TCE) and perchloroethylene (PCE, also known as tetrachloroethylene) from the 1950s through the mid-1980s. Both chemicals are known to have adverse effects: TCE is a carcinogen and may cause adverse pregnancy outcomes and PCE is likely to be a carcinogen as well. 

Because of these exposures, Marine veterans and their families have been concerned about risks for adverse reproductive outcomes, cancer, and other health effects; many had sought some form of compensation in the past. A committee of the National Academies—chaired by David Savitz, a visitor to the school this year—was tasked with addressing the risks of TCE and PCE for former residents of the base to bring some closure to the troubling and controversial issue. The committee understood the challenging context of their report and its implications for the exposed former residents of Camp Lejeune. The 2009 report from the National Academies concluded: 
 
“It cannot be determined reliably whether diseases and disorders experienced by former residents and workers at Camp Lejeune are associated with their exposure to contaminants in the water supply because of data shortcomings and methodological limitations, and these limitations cannot be overcome with additional study. Thus, the committee concludes that there is no scientific justification for the Navy and Marine Corps to wait for the results of additional health studies before making decisions about how to follow up on the evident solvent exposures on the base and their possible health consequences. The services should undertake the assessments they deem appropriate to determine how to respond in light of the available information.”

In evaluating the evidence and the likelihood of adverse effects, the committee offered a fully balanced assessment following the “on the one hand” and “on the other hand” model. The fact of exposure to TCE and PCE was well established, but the epidemiological information on those who had served or worked at Camp Lejeune was insufficient to guide risk estimation for the purpose of compensation, as is done with ionizing radiation. The last sentence in the quoted text shifts the onus of decision-making onto the military services, making clear that the scientific evidence is insufficient to tip decisions in any particular direction. In the face of uncertainty and the National Academies report, the Department of Veterans Affairs previously moved forward with benefits under The Camp Lejeune Act of 2012. This act provides health care and healthcare funding assistance to eligible Veterans and family members who lived on Camp Lejeune during the specified time-on-station, and who meet service date requirements. The claimants also need to have one of the covered conditions, defined based on toxicologic and epidemiologic evidence on the chemicals of concern.

This is an example of presumptive decision-making, i.e., exposure is presumed to have occurred if the affected person meets the time-on-base requirements and the specified conditions are assumed to have been caused by the exposure. The presumptions bridge the evidentiary gap related to causation of the listed diseases by chemicals in Camp Lejeune’s drinking water and assume that individuals at Camp Lejeune were exposed. There is a similar exposure presumption for Agent Orange in the Agent Orange Act. I chaired a committee of the National Academies that addressed those presumptions in a 2006 report. The bottom line: we could do a much better job of tracking the health consequences of military service if adequate data systems were in place to support studies of exposed military personnel and veterans. Presumptions would not be needed to fill gaps, a recurring conclusion in public health!

The recent action occasioning the solicitations by lawyers is the Camp Lejeune Justice Act of 2022 is part of Congressional Act S.3373, which also addresses veterans exposed to emissions from burn pits and some other toxins. The Camp Lejeune Act frees veterans to file civil lawsuits against the government for harm caused by exposure to water at Camp Lejeune from August 1, 1953, to December 31, 1987. Packs of lawyers are on the hunt, looking for their cut of any awards received. Now, you know why Camp Lejeune has become so familiar. 
 
Last week, the Association of Schools and Programs in Public Health (ASPPH) released the report of its Taskforce on Climate Change and Health, co-chaired by Lynn Goldman, Dean of the Milken Institute School of Public Health at George Washington University, and me. The report represents a year-long effort by the taskforce. Its recommendations are timely and will receive attention from the leadership of the Colorado School of Public Health.  

 


Jonathan Samet, MD, MS
Dean, Colorado School of Public Health