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In February 2020, our crew talked about the emerging pandemic with epidemiologist and infectious disease expert Dr. Tara Smith from Kent State University. In this episode, we return to Dr. Smith to talk about what we’ve learned in the past two years and how the world and our society have changed because of COVID-19.

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Radha Velamuri:

Hello, everyone. Welcome back to From the Front Row brought to you by the University of Iowa College of Public Health. My name is Radha Velamuri, and I’m joined today by Alexis Clark. If this is your first time with us, welcome. We’re a student run podcast that talks about major issues in public health, and how they’re relevant to anyone, both in and out of the field of public health. Today, we’ll be chatting with Dr. Tara Smith, Professor of Epidemiology at Kent State State University College of Public Health. She previously spent nine years here at the University of Iowa in the department of epidemiology. Dr. Smith has published over 100 peer reviewed papers and book chapters and has received over $3 million in funding from the USDA, AHRQ and NIOSH. Dr. Smith was a guest on From the Front Row on February 3rd, 2020, just over two years ago. Today, we are excited to welcome her back to discuss what she’s been up to through this pandemic, and how life has changed since February of 2020. Welcome Dr. Smith.

Tara Smith:

Thanks for having me back.

Radha Velamuri:

Dr. Smith, can you give us a brief introduction to yourself beyond what we talked about, and what you’ve been up to since the last time you were here on the show?

Tara Smith:

Yeah, sure. In addition to my infectious disease based research and wet lab work and field epidemiology, I also do a lot of science communication. That has really been my focus over the last two years. I’ve written, since the pandemic, something like two dozen articles that have been published in the lay media. In outlets that are not just focused on academics. Trying to keep up with updates on what is happening with COVID, cover new publications that come out, and really just try to keep the public informed as the science has been changing. All of this has happened in the context of I’m a parent. I have my older son, my middle child, my daughter has already graduated. At the beginning of the pandemic, I had a senior in high school who graduated remotely, and a kindergartner at the time who finished his year remotely and then was in remote school for all of first grade. He’s back now into school in person, but that was a lot to deal with as a parent and scientist.

Then I’ve also been part of my university’s Pandemic Response Committee. That really has been one of the biggest things is keeping tabs on everything so that we can quickly pivot whenever we needed to change policy or just try to foresee what’s going to happen so we can figure out what we’re going to be doing down the road. That’s been really what has consumed the past two years for me.

Alexis Clark:

How have you balanced during the pandemic being a parent and seeing that emotional toll that these impacts have had on your children versus the public health and scientist aspect of your life?

Tara Smith:

Yeah, I mean, it’s been extremely challenging. I’ve also been doing elder care for my mother. My father died right before the pandemic, and she needs 24/7 care. We’ve been sharing that with my siblings, so she is obviously very high risk. We’ve been trying to do as little as possible outside of the house especially in 2020 prior to the availability of vaccines, but also keep everyone entertained, not too much cabin fever, and keep up with everything. Of course, continue to teach. I’ve still been teaching remotely, and now back in-person, during the whole pandemic. It has been challenging. I don’t think balance is the word. It’s been a lot of juggling and a lot of dropped balls along the way. I think has been very common for a lot of parents, regardless what field they’re in. It’s been really just a challenging time, I think, for everyone.

Alexis Clark:

Yeah. I agree completely. The last time you were on the show, it’s really crazy to listen back, but we were at 560 deaths globally, 11 cases being in the United States. Two of those cases being confirmed transmitted by human-to-human interaction. Do you know, on February 15th, 2022, where are we now in terms of coronavirus stats in the United States?

Tara Smith:

Yeah, I did check into that this morning. For reported cases, which again, we know are certainly an underestimate, but these are the ones that have been recorded by public health. We are at about 78 million reported cases in the United States since the start of the pandemic and about 920,000 reported COVID-19 deaths. Early on, when we were looking at some of the early models, some of them had predicted a million deaths or more. I was honestly quite skeptical that we would get to that. Early on, I really had a lot of optimism. We were a country. We had pandemic plans. We have gone through all of this, at least, in what we call tabletop models where you have a scenario and try to figure out the best way to address it. We had done those over and over. We were wealthy. We had amazing science, so a million deaths seemed completely unrealistic to me, in February of 2020. Now we are almost at that point. It’s really disappointing to see how this has played out over the last two years. I really do think it didn’t have to be this way.

Radha Velamuri:

I’m curious about the tabletop models. Could you maybe explain that for people in our audience, or myself included, who may not really know what is involved in those? Do you consider public opinion and political situations? What do you consider in these models when you’ve come up with… I feel like they’re always changing.

Tara Smith:

Right. Yeah. Usually those, public opinion and politics, are not addressed as much. Which I’m sure they will be in the future because I think that’s been one of our big failings. Usually you can do these, different groups can do them, but say the state public health department may put one on. There would be a scenario that everyone has given and it includes people from public health, emergency management, fire, police, government, things like that. Anyone who would be a player in the response should either be involved or have a delegate who could come in and play their role. You get a scenario. There’s three cases of a novel coronavirus in China, and now one has been detected in the US. What do you do?

You figure out who you need to have involved, who you’re missing, what your response plan could be, what you’re missing there, supply chain logistics, things like that. Do you have all of these things available? Is this something that can have a vaccine developed? All of these things that you’re trying to role play, and then once you get past the first step, okay. Then you’re given an update to that scenario. It’s two weeks later and here’s the situation now. You basically just try to figure out where your limitations are, who you’re missing, where you need to strengthen your response. These are something that is done by lots of different agencies sometimes, maybe not yearly, but maybe every five years or so to update this.

We had a lot of practice in this, but obviously it had been a while since we had had a really serious pandemic. The last pandemic that we had was in 2009 with H1N1. I guess, luckily at the time, that wasn’t a very severe virus. It was very contagious, spread very quickly, but it did not kill a lot of people. Maybe we got a little bit too complacent when we saw that one, and how relatively well that went compared to COVID.

Alexis Clark:

As a public health expert, how did you and your team work through not having a large amount of data to predict what was going to happen next?

Tara Smith:

Yeah, that’s still tough. We’re still trying to figure out what happens next. A lot of what was done early on was based on both the data that we had coming in, which was really a fire hose, even though it wasn’t always enough to act on. We got a lot of data very early on about the virus, about transmission, about its epidemiology, a little bit about its pathology, pretty quickly, all things considered. It didn’t always tell us how to drive policy from that which is the big limitation.

A lot of that came from really looking back at 1918 influenza because that’s really the last time we had a pandemic of respiratory virus of this magnitude. Trying to figure out what had worked then as far as things like community shutdowns, distancing, things like that. Trying to extrapolate them to use in 2020. We’re really where we started with a lot of that. Then we just tried to change as new data came in. Some of it, again, is not always strictly based on science, but as you mentioned, is based on also the politics and what is happening in the public at the time. Trying to incorporate all of that, I think, were some of the big challenges beyond just having gaps in the science data that we had.

Radha Velamuri:

I’m curious about your data sources. Purely because there’s just so much out there, I bet, with vaccine reporting and positive case reporting. I don’t know if there’s negative case reporting. With the take home kits too, that’s a pretty recent addition. How all of that data helps you.

Tara Smith:

Yeah, like I said, sometimes it’s a fire hose. I tried as much as possible. In Ohio, we do have a state level coronavirus tracker that includes test positivity, cases per day, hospitalizations, ICU. A little bit of data if you dig down into the spreadsheets on gender, race, age, things like that. I kept tabs on that. I didn’t obsessively analyze it all the time because that’s a job. Look at what is happening both statewide and locally because you can also look at it just by what’s happening in your county or your zip code. I mostly have focused on that since, again, I served on the university committee to try to take care of things here. Also, of course, kept tabs on what is happening more broadly in the United States and also around the globe. Looking at data from that.

A lot, also, has come from the scientific literature, and that even has been so hard to keep track of because since the beginning of the pandemic pre-print servers have really exploded. Places where scientists can put their manuscripts before they’ve undergone peer review and been published in a journal. There are two that have a lot of COVID papers that are bioRxiv and medRxiv. Trying to do, usually weekly, searches just to see what new papers are popping up, and if they’re relevant, especially to the epidemiology which I tried to keep track of as much as I could. Vaccine developments, especially in late 2020 and early 2021, as some of those papers were coming out with the first publications of vaccine data were really important as well. It’s really a mix of trying to keep track of the raw data as far as cases and testing and things like that. Also, what is going on in the scientific research area as well?

Radha Velamuri:

Yeah, for sure. I think we should switch gears. We’ve talked a lot about data and models and all that, but let’s switch to quarantine. At the time of our previous interview, China had roughly 50 million individuals in quarantine. Now, worldwide, it’s a lot more. Can you talk about your opinion on the United States quarantine? Do you think we lifted it too soon, or were there any periods of time that you felt warranted for us to go into quarantine again as a country?

Tara Smith:

Yeah, we never really had a quarantine as a country. When you look at what other places like China did. Completely locking things down as far as travel and things like that. Other countries that had lockdowns where individuals could not go more than a few hundred feet from their house or something like that. We never had anything like that. It varied a little bit depending on geographic area, but we had some moderate shutdowns where, for example, again in Ohio, we were one of the first states to start shutting down things in early March of 2020. Closing restaurants for inside dining and shutting down movie theaters and gyms and things like that where people could gather that were not essential. We only did that for a short time and really opened things up without any plan.

I think that was one of our first mistakes. If you impose these sorts of things and then do it without any real reason to open back up, looking at either case counts or… What we were arguing for in public health was that to open things back up more fully, we should have in place procedures to test, trace, and isolate. That you could open up safely and identify cases and trace their contacts so that anyone who was exposed could go into their own quarantine. Anyone who was identified as a case could go into isolation. That would be a more systematic way to keep the virus from spreading the population. We never had that. Even when we did finally get a test, trace, isolate program, it was mostly used in times where we had really high case numbers. By that time it was almost too much. We couldn’t identify all the cases and certainly couldn’t identify their contacts. We’ve never had a really good way to do that in most parts of the United States.

People talk about quarantine, lockdowns, and things like that, but as a country, we certainly never had anything. I think that’s also one of the limitations that we didn’t get to, as much, in some of these tabletops that I mentioned. Looking at the differences between what the federal government could do versus what the state government could do. Especially how different the reactions could be between different states because some of them like New York and Washington state did have more lockdowns, not really. More stringent quarantines that were put in place then someplace like South Dakota which never did anything basically. There was such variation between states that it’s hard to make any generalizations to anything as a country because we never did anything really as a country.

Radha Velamuri:

I like how you said test, trace, and isolate. It sounds really simple, like a little tagline. It seems like achieving it is anything but simple. Like a feat in itself. I’m curious as to, if you think there were any confusing elements in quarantine suggestions and guidance on the individual level, as not all of us are public health professionals, the average person. COVID is getting more and more increasing. When someone finds out that they have COVID, do you think that the steps are clear for what they should do? Or is there confusing guidance out there on the individual level?

Tara Smith:

Oh yeah, I think it’s so confusing. For one, the terminology when we started out. Quarantine is used when an individual is exposed but not yet sick. Isolation is the actual term for when you are sick, and you are put in isolation away from other people. Quarantine, as a term, just got used for all of that, I think. When that’s not really appropriate, so that led… I saw a lot of comments on local news sites and things like that. Which I try to keep tabs on just so I know what some concerns people have. Over and over I saw repeated that in the history of the United States quarantine has never been used for healthy people. Well, that’s literally the definition of quarantine, is a healthy person who is exposed.

I think all of that, the science, the communication of it, got really muddled. People didn’t always understand why you had to quarantine. Previous instances where this had been used in the United States. Absolutely, it had been used before. I think this extended to masks as well. Why did a healthy person have to wear a mask if they weren’t sick? Well, you don’t know that you’re not sick. You could be spreading the virus. That’s why we want everyone to mask. I think a lot of that just got horribly muddled early on and never really recovered from that.

Then with the quarantine and isolation guidelines, those have changed over the pandemic as we’ve learned more and as different variants have popped up with different incubation periods. Trying to keep tabs on those has been so difficult because they have changed from the CDC and then each state can decide if they want to accept the CDCs guidelines or not. What may be a talking point in public health departments in Ohio, who have accepted the CDCs guidelines, may not be accepted in public health departments in another state which did not accept the CDCs guidelines. I think it just became a huge mess. Again, it’s something that you had to look at state by state. If I was doing an interview with a reporter in New York or something, I couldn’t be sure that they were using the exact same guidelines that we were using here in Ohio. It has been, I think, a mess to try to keep all of that straight.

Alexis Clark:

As we have progressed through this pandemic, we have seen new variants of the coronavirus every few months it seems. How is this specific virus able to mutate so quickly?

Tara Smith:

Yeah. It has a few things to its advantage. One is that it is an RNA virus. RNA viruses just tend to be much more mutable than those with DNA as their core genome because RNA is just easier to change. Coronaviruses are a little bit unique. They’re not quite as mutable as something like influenza which is also an RNA virus. Influenza is more able to swap parts of its RNA with other influenza viruses. That’s why you can get some of these hybrid, pig/duck, influenza viruses that can then maybe go on to infect humans. Coronaviruses don’t do that in quite the same manner. They also actually have a correction enzyme so that if they do get a mistake in their RNA, they can correct it. Amazingly, coronaviruses could be even more mutable than they are.

What they have also in their advantage is just that they’re infecting so many people every single day. It is in their advantage, generally, to mutate. Especially if it’s something that will provide the virus with a selective advantage like we’ve seen with every variant that has come up. They’re a little bit better at getting around our immune response. Not surprisingly, as more people have some immunity as the pandemic has progressed either from vaccines or from infection, that if a virus evolves that can get around some of that protection from the host, they’ll have a selective advantage. If they can get into a population and then spread from there, some of those will spread in a manner that takes them out of their local geographical niche, and they can spread worldwide.

That’s what we’ve saw with the UK variant, early on. With Delta last summer. Now with Omicron this fall and winter. Each one is a little bit better at spreading in humans. We look at what’s called the R naught, or the basic reproductive rate, of this path that tells us, on average, how many people they spread to from one infected individual. We’ve seen that creep up over the pandemic with these new variants. That has increased with each variant that has come out.

Radha Velamuri:

You really went into a lot on the mechanisms of viruses. That was super helpful. This is a really broad question. We might not have an answer for this, so it’s okay if the answer is you don’t know. Do you think that we will ever fully eradicate this virus? I know coronavirus like different versions, different types of coronavirus have existed for years, but do you think that the end is in sight?

Tara Smith:

As far as eradication? I don’t. I think so. There are different ways to consider the pandemic ended. Some have to do with biology and some have to do with just politics. We are already, I think, in this endgame as far as paying attention to the coronavirus. Doesn’t necessarily have anything to do with biology because right now we are still seeing about 200,000 cases per day in the United States and 2,500 deaths. I think a lot of people are just over it. That’s one way that these things can end is that it just becomes something you just deal with every day.

The other is, of course, that it could be eradicated as smallpox was. Smallpox had a lot of things going for it that coronavirus does not. Smallpox was only a human pathogen. It didn’t have zoonotic reservoirs. It wasn’t present in other animal species. It was very obvious when someone had smallpox. You could see that very clearly versus coronavirus, of course, we have people with very mild infections or even completely asymptomatic infections. A lot of potential spread of coronavirus can go on without being detected which makes it much more difficult also to eradicate. The vaccines we have for coronavirus also are really good, but they don’t fully stop transmission. With smallpox vaccines, also, you could still get these breakthrough cases, but they were pretty rare. Most people who were protected when they were vaccinated from smallpox, they were protected basically lifelong. We know that coronavirus immunity wanes pretty quickly. Whether it’s from vaccination or from an actual infection. All of those characteristics that smallpox had coronavirus is just very different.

That makes it a lot more difficult to eradicate when it has animal reservoirs, when it has vaccines that are not great at preventing infection outright. That wane over time. I think this is a virus that is going to be with us basically forever. It’s going to become the next endemic human coronavirus is my guess if I had to put money on the table. That means we have to figure out what we’re going to do about that.

We still don’t have global vaccine equity which is one big issue. We have great access to vaccines in the United States except for young children right now. They’re the only group that cannot be vaccinated as a whole. So many developing countries lack access to vaccines, even in groups like healthcare workers. I think that’s one thing we need to really work on in this year, in 2022, is getting the rest of the globe vaccinated. Ideally what we can do is, even if we can’t get rid of this virus, we can make it into something that is not as much of a threat. If we have global immunity to this, even if it doesn’t keep us from getting infected outright, it will definitely minimize the number of serious cases, the number of people needing to be hospitalized for this, ICU utilization, and death. We can basically tame this virus into something that is more of a nuisance and less of a significant everyday threat. That’s where I hope we’re going.

One gap that I still see with that though, is the idea of long COVID or these long-term chronic effects from viral infection. We still have some questions about how either a vaccine induced immunity or infection induced immunity, how they can protect from long COVID. It looks like, at least with vaccines which I think is the best data we have, that vaccination does seem to dramatically reduce the risk of getting long COVID if you are infected. That’s still a black box that we’ll have to be dealing with, again, here in the United States, but also globally where they might not have as many resources to work with a population whose disability and chronic conditions have increased over the past two or three years. I think that’s something that we’ll have to be sorting out as we go forward.

Alexis Clark:

I think it’s really a powerful thing that we, as a globe, as a worldwide effort, should be looking to work together or else we’ll never see a true taming of this virus.

Tara Smith:

Absolutely. I don’t like to be US-centric. If we can vaccinate the globe, get immunity to everyone else, that also does reduce our risk of being infected with new variants that may pop up in individuals, especially without immunity. We saw the last one was first identified in South Africa. It doesn’t have to be in South Africa. We have a big unvaccinated population here in the United States as well. Increasing global vaccine equity will protect everyone from the generation and spread of those new variants. I think that’s something, also, we need to do for selfish reasons to protect ourselves, but also just to protect everyone else also around the globe.

Alexis Clark:

Yeah. I couldn’t agree more. Well, Dr. Smith, thank you so much for coming back onto From the Front Row. Do you have any closing comments you’d like to make as we end today’s podcast?

Tara Smith:

I would just argue for vaccination. Hopefully your audience is a highly vaccinated one, but if they are not, it’s really, I think, so important both to protect yourself. We’re still in the pandemic. It still hasn’t ended, no matter how much people would like it to. That’s one small step to take to work toward that end, I think.

Alexis Clark:

Absolutely. Thank you so much, Dr. Smith.

Tara Smith:

Thank you.

Alexis Clark:

That’s it for episode this week. Big thanks to Dr. Tara Smith for coming on with us today. This episode was co-hosted and written by Radha Velamuri and Alexis Clark. Edited and produced by Alexis Clark. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple podcasts, and SoundCloud. If you enjoyed this episode and would like to help support the podcast, please share it with your colleagues. Our team can be reached at cph-grandambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Stay happy, stay healthy, and keep learning.