Yes; this is bad

Don’t panic but do not brush off the public health warnings of Coronavirus. Emerging consensus is that containment might have been possible a few weeks ago, but is no longer realistic. Although China bought us all time, we did not use it effectively. We have entered the pandemic phase which will be followed by seasonal recurrence of the disease unless and until we have a vaccine (which may not be available until 2022). Further, recent evidence suggests that asymptomatic people carrying the virus are spreading it. This makes it much more difficult to contain and social distancing measures even more critical.

This is not a normal flu

Not even in the best case

The World Health Organization estimate of 3.5% mortality rate is an average across age groups. According to Centers for Disease Control and Prevention director Dr. Robert Redfield, up to 25% of cases are asymptomatic, and they are infectious. COVID-19 is likely three times more infectious than flu. Data from Iceland suggests as many as 50% of cases may be asymptomatic. There is very strong consensus that those aged 60+ and those with underlying conditions are the most severely impacted.

Chart showing COVID-19's mortality rate tops at 14.8% on adults over 80 years old, and is less than 1% on people under 50

Earlier in the pandemic, there was hope that the 3.5 percent figure was grossly overestimated. However as evidence continues to emerge, there is dwindling support for that hope. The numbers out of South Korea are so far the most optimistic in the world (0.7% cases were fatal); however, a) the South Korean population is younger on average and b) South Korea (in contrast to the USA) have been doing everything right from the earliest stages of the outbreak: they have done massive roll out of testing coupled with radical transparency, public support and brilliant drive-through testing! If this strain of coronavirus is like other viruses, aggressive measures that reduce transmission may also lower the average ‘dose’ of viral particles that cause any given case; this might reduce the average severity of disease and decrease overall death rates. Time will tell.

Moreover, even IF the true COVID-19 mortality rate is as low as 1% (as it is so far with the Diamond Princess), that would already be ten times higher than the mortality rate of a typical seasonal flu.

Bar chart showing COVID-19 mortality rate estimated between 0.5% and 4.0%, versus Seasonal Flu at 0.1%

The 61,099 flu-related deaths in the U.S. during the severe flu season of 2017-2018 amounted to 0.14% of the estimated 44.8 million cases of influenza-like illness. There were also an estimated 808,129 flu-related hospitalizations, for a rate of 1.8%. Assume a COVID-19 outbreak of similar size in the U.S., multiply the death and hospitalization estimates by five or 10, and you get some really scary numbers: 300,000 to 600,000 deaths, and 4 million to 8 million hospitalizations in a country that has 924,107 staffed hospital beds [for all illnesses combined].

For most people, infection results in a mild but still transmissible illness; that is how it spreads. Those that get severe illness are hit really hard. Mortality is not the full picture: Italy reports that 10% of cases need not just hospitalization but also ICU care – and they need that care over a period of 3-6 weeks. This is unsustainable.

Keep the main thing the main thing

#FlattenTheCurve

A lot of ink has been spilled on speculation about the “true” rate; however we are still in the early phase of the pandemic and it could take years to precisely determine the rate. BUT we know that it is somewhere between .5% and 4 percent mortality; this range is more than adequate evidence to warrant decisive, immediate, large-scale preventive action. Far and away, the most important thing to do is flatten the curve of the epidemic so that our health systems can cope and to give time for the scientists to research vaccines and treatments.

It is here

Assume that the virus is already in your city / town / workplace / church / etc. It almost certainly is “here” and is simply not yet detected due to the shortage of tests. Moreover there are 6 states that still don’t have a single lab ready to carry out the test even if they had one in their hands. Estimates from Italy are that in the early outbreak, the number of actual infections was four times the number of cases than it was possible to confirm at the time. Cryptic transmission in the community was happening for weeks before it was detected in Seattle. Seattle and Stanford are doing an amazing job of getting up to speed with their own testing kits; about 5-7% of tests in Seattle are positive and anyone (with a doctor’s indication) can be tested.

Frustrated by the lack of testing resulting from the problem with the CDC-developed kit, the Seattle Flu Study began using an in-house developed test to look for COVID-19 in samples from people who had tested negative for flu. That work —permissible because it was research— uncovered the Snohomish County teenager.

(For the sake of public health, University of Washington are publishing these results). So far only UW and Stanford have been moving ahead with their own (non-CDC) testing; both of these institutions have mandated that in-person classes be moved to distance learning alternatives. That speaks for itself; more universities should follow suit. That said, professors need the technology and support to make this switch.

Education communities that are resource-poor (without laptops or internet) would have the hardest time doing this switch. So let’s start with those universities (and disciplines) for whom this switch is not such a major hardship. There is no one-size-fits-all intervention, but speed is key. Professors, please don’t wait for your university administration to make the decision campus wide. Move to a distance-based option of your own accord. Check out these tips for teaching online in a pinch.

No country is fully prepared, including the United States

Although the WHO’s JEE report from 2016 rates the US highly in preparedness for a public health emergency, a Johns Hopkins University study noted that “there appear to be significant gaps in pandemic influenza and other infectious disease outbreak planning among the hospitals”. According to the IHME’s projections from April 1st, “the US is predicted to need 262,092 total hospital beds (39,727 for ICU), and 31,782 ventilators to support COVD-19 patients. This demand on hospital resources could lead to a nationwide shortage of 87,674 total hospital beds and 19,863 ICU beds given current COVID-19 trajectories.” We simply don’t have the equipment, training, or messaging in place and we need to ramp up fast. No one does. That is why your choices today matter so much.

Those of us with colleagues in Northern Italy (the region hardest hit) know they have exceptional physicians, infectious disease docs, and immunologists. They also have effectively universal care, so this is not a developing-world tale that is irrelevant for the US situation.

Certain policies are more effective for pandemic control

  • Universal healthcare coverage.
  • Universal guaranteed paid sick leave.
  • Paid sick leave duration of 4-6 weeks.
  • Guaranteed paid family leave (to care for sick members).
  • Coordinated financial or operational support for people who should self-quarantine.
  • Policies that incentivize insurers to provide rather than withhold care.
  • Policies that separate health care from employment. (Otherwise when people get sick they are also vulnerable to bankruptcy, or when unemployed lose healthcare. In a pandemic year both are devastating.)
  • Clear, truthful, and transparent public messaging at all levels about the seriousness of the threat and what ordinary people can do to help.

The fact that such policies have not previously existed in some countries complicates the behaviors required to #flattenthecurve.

There is a nice summary here of the public health measures that are also vital to an effective pandemic response

There is hope. You’re it. That’s the work

You can help by following as much as possible of the following guidance. The earlier the precautions are taken, the more precautions are taken, the more lives are saved. It is that simple. Expect yesterday’s under responders to be today’s over-responders. Resist the urge to ricochet or give up hope. The key is to stay calm and do the steady work of infection control and urge others to follow suit.

From a dear friend in Beijing “Use wisdom but don’t allow the pandemic to become an empty excuse for not loving your fellow humans. Choose generosity instead of hoarding. And on those really hard days (or maybe after watching too many news reports) turn up the music and dance! Celebrate the goodness! It’s there, it will remain and you can be a catalyst for it!”

Here’s how.