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COVID-19 : What's Next?


A look at what to expect next amidst the COVID-19 Global Pandemic

Background

I earned my MPH with concentrations in Health Policy and in Epidemiology 15 years ago from the University of Illinois School of Public Health. On March 8, 2020 I wrote a piece on what COVID-19 is and why we should take it seriously.

In this piece, I'll examine what we can expect to see next amidst a global pandemic. As a reminder, I'm not here to scare you. If you're already taking COVID-19 seriously, I'm going to present you with facts, data, and links to help you better understand the situation.

If you are not taking COVID-19 seriously, I'm begging you to look at the data, because it may just help you save the health and well being of a loved one. You don't have to agree with me. You just have to care about not starting an infection vector that could ultimately hurt the people you love.

One last comment before we begin - there are a lot of people out there who can't fend for themselves in this environment: senior citizens, prisoners, the homeless, orphans, etc. Not to mention those who are living week to week or paycheck to paycheck, including retirees who have lost a great deal of their retirement fund.

Let's not forget to look out for our fellow man here. People are going to be without wages, businesses will be without meaningful income, families will be juggling a lot, and healthcare workers will be risking it all for our collective health. And remember while we are in self-quarantine, someone is out there driving trucks, stocking shelves, and making the world go round.

We are in this together. Let's please act like it.

Introduction

I enjoy a good game of chess. I also enjoy diving into game theory economics. What do these two have in common? Well, other than being sure fire signs that I'm a massive nerd, both challenge individuals to always think several steps ahead. So let's try to apply that mentality here and see if we can identify what we're likely in-store for in the months ahead.

Before we dig in, let me say this: I hope that I'm wrong about how serious COVID-19 is and will be. When I look around, I feel like this is no big deal. I can't, or at least don't want to, conceptualize how the horrors that today face Italy (and others abroad) could materialize here.

But the data...the data says otherwise. The data says we are in for a bad stretch, especially because we are taking a less aggressive approach to this situation than are other nations. Our testing ramp up was slow so all our case numbers are under reported and we don't yet know where our cases of infection are.

Our implementation of lockdowns is slow. The degree to which our "lockdown" relies on voluntary compliance is far more relaxed than that of other countries, many of which are virtually implementing martial law. We have not yet even fully implemented temperature checks and quarantine checkpoints yet.

So while my heart says this is no big deal, my head says this is a very serious situation. At times like these we must follow the data and let it lead us to where it will without passion or prejudice.

The Ghost of Christmas Past

Before we look forward, let's take a quick look back at a few past epidemics.

  • The spanish flu pandemic of 1918 infected 500 million people worldwide (1/3rd the world's population at the time) and had a case mortality rate of 2.5%.

  • The death-to-case ratio for paralytic polio was generally 2%-5% of children and 15%-30% of adults and it took decades to find a vaccine for the virus.

Why do we need to take a quick peak back? For two main reasons. First to show how COVID-19 is actually more infectious and lethal than the spanish flu of 1918-1919, let alone far more dangerous than our present flu (COVID-19 is between 10 and 50 times more fatal than the current flu). Secondly to show that a lethal virus like Polio can torment us for years before a vaccine is discovered.

Spanish Flu vs. COVID-19

Ironically, many people appear to be caught up in saying that the novel coronavirus SARS-CoV-2 which causes COVID-19 is no big deal because it is just like the flu. The problem is, it is like the spanish flu of 1918-1919, not the current flu we are used to.

  • Whereas the spanish flu infected a third of the world's population, COVID-19 is projected to infected two thirds of the world's population.

  • According to the World Health Organization, COVID-19's mortality rate is nearly 40% greater than that of the spanish flu.

  • The modern flu has a mortality rate of 0.1% in the US. COVID-19 has a mortality rate of 3.4% worldwide, but is exhibiting a 5% mortality rate in Italy.

Polio vs. COVID-19

From 1916 onward a polio epidemic appeared each summer in at least one part of the United States with the most serious occurring in the 1940s and 50s.

1952 was the worst polio outbreak in the nation's history with 57,628 cases reported that year and 3,145 deaths.

What does this tell us about COVID-19?

For one, there's no guaranty that the SARS-CoV-2 virus will burn out when the weather gets hotter - Polio cases flourished in the heat.

In fact, some of the harder hit COVID-19 nations are in the southern hemisphere and were in the midst of their summer seasons when the outbreak began. So, there is no evidence presently to suggest that COVID-19 will dissipate in the summer. Even if it does dissipate, which we hope it does, the prevailing thought is it will resurface in the fall as a seasonal virus.

Secondly, Jonas Salk worked seven years on his polio vaccine, which was successfully made public in 1955 - 3 years after the most deadliest Polio outbreak in the country. This is to say that while we all hope a vaccine for COVID-19 is found as soon as possible, the earliest a deployable vaccine will likely be available is sometime next year, but there is no guaranty we will find a vaccine that quickly.

The Ghost of Christmas Present

COVID-19 data is moving so very fast it's hard to know what our status or trend line is at any given moment.

As referenced with citations in my previous article here's what we do know about the current global situation:

  • Experts believe up to 70% of the world's population will be infected with COVID-19.

  • Angela Merkel has already informed her nation that 70% of Germany may contract COVID-19. Germany is now on lockdown as is France.

  • Experts believe that over 60% of the UK may be infected as well as their leaders ponder a herd immunity approach over a flatten the curve approach.

  • Even Canada has closed its borders.

  • Italy is currently experiencing a spike in cases and deaths far greater than most other nations - Italy may be facing a case mortality rate of 5%, which is approximately 1.5 times that of the WHO's stated 3.4%.

Here's what we know about our current domestic situation:

The Ghost of Christmas Future

So what's next? Where do we go from here? Let's take a look at the possible decision tree options here.

Option 1: Best Case Scenario

Our best case scenario is that the number of cases in the US simply grinds to a screeching halt and/or stops being as lethal as it is.

It is believed that in 1919 the spanish flu finally dissipated for unknown reasons - possibly as a result of herd immunity, possibly because it mutated into a far less lethal strain.

If we are able to quickly discover a course of treatment that severely mitigates the most severe damages caused by COVID-19, then we too end up landing in our best case scenario.

Unfortunately, this scenario is unlikely because we have no indication COVID-19 will, of its own accord, dissipate nor do we have any indication we are less than several months away from a clinically tried trusted and approved way of even reducing the severity of the respiratory disease that afflicts patients in the most severe and lethal COVID-19 cases.

Option 2: Worst Case Scenario

The worst case scenario is one we don't want to think about let alone talk about. It involves an acceleration in infection rates, mortality rates, more lethal mutations of the virus, and a wide sweeping decimation of our health care system.

Some might say the updates we're getting from Italy already sound a bit like the worst case scenario. I say let's pray we never truly understand what this worst case scenario could look like.

Option 3: Something in the Middle

In truth the middle scenario(s) on the decision tree is not one wide sweeping all encompassing middle option. It's comprised of countless smaller scenarios that account for a wide array of variables. But to simplify matters lets just talk about what we're likely to face somewhere here in the middle of the two unlikely extremes.

Follow the Data

It appears certain that things are going to get worse before they get better, but if we all do our part, we may just make it through this together.

The likely short term outlook is likely to consist of some of the following:

  • The need to call in federal agencies, national guard, and military resources to address a severe strain on the healthcare system. This may include building added hospital capacity or even having military medical personnel serve as reinforcements for civilian medical professionals.

  • The need to more strictly impose a more aggressive flattening of the curve.

  • The need to understand that this situation will last for months not weeks.

  • The need to identify and aid the people most likely to slip through the cracks

Support for the Healthcare System

Let's do some math here shall we?

There are roughly 330 million people in the united states. Let's say approximately 70 million are over the age of 60 and/or are immunocompromised. This is likely underestimating the true number of the higher risk population.

If we conservatively figure a 20 percent infection rate in our highest risk population (remember experts are predicting 40-70 percent infection rates worldwide across all population segments) then we are left with 14 million infected individuals in the highest risk population.

Let's round that down to 10 million for the sake of being ultra conservative and ultra optimistic.

Now let's say that of these 10 million infected high risk patients, 15% require hospitalization. That's a very conservative percentage given we're talking exclusively about the high risk population. Especially when you consider that 14-15% is the current hospitalization rate for the general population at large in COVID-19 patients.

So that means we will need about 1,500,000 hospital beds for COVID-19 patients. Unfortunately, on average there are only 300,000 available hospital beds at any given time in the US as the rest are usually occupied by non COVID-19 patients. So we will need 5 times as many available hospital beds as we currently have nationwide in this very conservative scenario.

A more simplistic way of understanding the problem is this: The United States has a total of 2.8 hospital beds per 1000 people. By contrast Italy has 3.2, China has 4.3 and South Korea has 12.3. Yet public health experts believe there will be at least 400 per 1000 people infected with COVID-19 and 60 per 1000 will need a hospital bed in the US.

Now let's say that of the aforementioned 10 million high risk infected patients we assume 5% need to be in the ICU. Again this is very conservative since we're only talking about the high risk population. Especially when you consider 5% is actually the estimated COVID-19 ICU admission rate for the greater population at large, with the ICU rate for high risk populations estimated to be significantly higher (likely by a factor of at least 3).

All this math is to say we'd conservatively need 500,000 ICU beds. It is presently estimated that we have anywhere from 45,000 to 70,000 ICU beds in the United States. By that math we need more than 7-10 times the ICU beds we currently have just for COVID-19 patients. This does not take into account that normally 60-80 percent of ICU beds are usually occupied as it is.

If we add in the additional 46,000 beds that could be converted to ICU beds in a crisis we'd still need more than 4 times as many COVID-19 ICU beds alone - not accounting for other patients!

To show just how conservative my estimate of 500,000 ICU patients is, according to Medscape citing a report from Johns Hopkins, the US could find itself in a situation where as many as 2.9 million people need intensive care, leaving an ICU bed deficiency greater than 20 times the current amount.

This shortage doesn't even breakdown the inventory vs. the need of ventilators.

What's the deal with the ventilators you ask? Well, COVID-19, in severe cases, causes / results in ARDS which stands for Acute Respiratory Distress Syndrome. Approximately 20-30% of hospitalized patients with COVID-19 and pneumonia require ICU care for respiratory support. Data out of China suggest that 50% of patients hospitalized for COVID-19 develop ARDS and 50% of those are unlikely to survive.

Based on the above calculations we get anywhere from 500,000 to 3 million patients that may need a ventilator to assist with their breathing. US hospitals have 160,000 ventilators: 62,000 full featured ventilators and 98,000 more basic ones that can be used in an emergency according to a 2020 study by Johns Hopkins University.

If COVID-19 turns out to be like the spanish flu of 1918 we may be looking at a need of 740,000 ventilators or more.

No matter how you slice the data or which set of reasonable assumptions you use, we are going to be severely short on ventilators. This doesn't even touch upon the shortage we are going to see in the doctors, nurses, respiratory therapists, and other critical hospital personnel we are going to need to deliver the care these patients need.

Not to mention that because of COVID-19, blood donation and blood drives have drastically declined causing a potentially critical supply shortage.

The message is loud and clear. If we are not able to quickly and severely curb the spread of COVID-19, we are going to be short hospital beds, ICU beds, ventilators, healthcare personnel, and even blood supply.

In Chicago schools, vacant lots, stores, and even sporting arenas are being considered as make shift expanded hospitals, should the need arise. In fact, you may not have heard but we already have military installed quarantine camps underway at major US airports.

With respect to healthcare personnel, due to a lack of protective equipment along with repetitive and intense exposure to COVID-19 patients, our healthcare professionals are themselves running an increased risk of contracting the disease.

At a fundamental systemic infrastructure level, we need help. The healthcare system needs help. For this reason there have been calls from mayors and governors to activate the National Guard and aspects of the US military to build facilities, provide healthcare personnel reinforcements, and take over critical supply chains; as well as calls for the federal government to tap the nation's strategic national supply so that hospitals can get the equipment they need.

What is inescapable is that we must drastically and rapidly "flatten the curve," for we are already on course to exacerbate the resources of the healthcare system as we know it.

Flatten and then Flatten and then Flatten some More...

By now you're tired of the phrase "flatten the curve." If you're not, you haven't heard it enough. If so...tough noogies - get used to hearing it, get used to saying it, get used to living it. It is your friend. It may just save the lives of people you care about - maybe even your own.

Flattening the curve means reducing the rate at which cases in this country pile up, specifically in flattening the peak number of cases on the curve, and spreading them over a longer period of time. The goal is simple. If we can smoosh the peak number of cases down and push them out over a longer period of time we can reduce the stress on the healthcare systems. If we're successful enough to reduce the peak to a value below the capacity line of the healthcare system which denotes the cap on their ability to treat that number of patients at any given time, then we've effectively alleviated the strain and avoided the overrunning of hospitals. This is the goal.

The easy way to understand or explain flattening the curve is as follows: think of it as the reverse chickenpox. When I was a kid, if one sibling got the chickenpox, parents would put all the kids together so they all got it and got over it together in one shot. That's the opposite of flattening the curve.

So why do we flatten the curve with COVID-19? Imagine if the entire neighborhood stayed at your house when one child got the chickenpox so the entire neighborhood could get it and get over it in one shot. Your house would be overrun. Where would everyone sleep, bathe, go to the bathroom? How would your parents be able to take care of everyone? How could they afford the supplies? They'd probably get some other illness themselves from sheer exhaustion. The system would breakdown. Now pretend it was the whole city instead of the neighborhood. How quickly would that system break? How badly would it break? This is why we flatten the curve with COVID-19!

This is why we must all engage in strict social distancing. This is why we must all do everything we can to avoid contributing to the spread of COVID-19. This is why I'm dumbfounded at all those individuals that went out to celebrate St. Patrick's Day despite major cities cancelling parades and other events. I'm also not thrilled with the massive shoulder to shoulder lines at airports that are most certainly not complying with social distancing guidelines.

Each of those individuals is now a possible infection vector. And why does that matter? Because South Korea recently traced a super spreader where one woman appears to have directly caused 37 cases of COVID-19. Similarly, the outbreak that caused the New Rochelle quarantine, under National Guard watch, began with 50 cases that were traced to one individual. Imagine how many cases the St. Patrick's Day party goers may cause?!

The challenge is that quarantine in America, short of martial law or federal mandate, is largely optional. And we are showing ourselves to be unreliable to voluntarily adhere to self quarantining and social distancing. This is why it is inevitable that we will soon face much stricter and more mandatory / forcefully enforced quarantine rules and curfews.

Just today the CDC issued an 8 week quarantine recommendation for the entire country for gatherings over 50 people. The government expanded the restriction to limiting gatherings over 10 people shortly thereafter. San Francisco just issued a strict quarantine curfew for nearly 7 million people.

These restrictions pale in comparison to quarantines in China, Italy, and other nations around the world. The US quarantines must escalate rapidly and with severity in order to truly flatten the curve.

So be prepared for it. Be prepared for domestic airports to be shut down. Be prepared for police, national guard, etc to be called in to enforce quarantine check points. Be prepared for temperature checkpoints to be a part of your life for the next few months.

Hope for the best - hope this doesn't come to pass. But please be prepared for it to become a reality.

Months not Weeks

When schools and companies started shutting things down just a few days ago, the situation appeared to be presented as one that would last a few weeks. The question to ask ourselves is why would we only be dealing with it for a matter of weeks, when Wuhan China has been dealing with it for 3 months - especially when they actually quarantined 150 million people in a military style lock down in January and implemented rapid & intense testing? Why would our version of selective elective social distancing be more effective and expedient than their draconian measures?

As of today, the government has changed its timeline and guidelines. This matter will last at least 8 weeks, and likely till August.

This does NOT mean you should go on a toilet paper run immediately. It does mean you should manage expectations that COVID-19 will be around for months to come, and so will school shutdowns, telecommuting, social distancing, intense hand washing, and all that goes with it. Do not let this degrade your sanity. Do not let it erode your compassion or humanity. But understand, if Italy and China, and the rest of the world are going through it. It is naive or arrogant to think we will be spared - though we can hope for the best, we must prepare for what's to come.

It's the People, Stupid

You may have heard of the phrase, "it's the economy, stupid." Well, contrary to popular belief, it's really about the people, not the economy. Especially, in the time of COVID-19. Because if you find yourself having to go to an overrun hospital in need of a ventilator being taken care of by a skeleton crew with half the doctors and nurses having to be quarantined due to exposure to COVID-19, you're not going to care about the economy.

You must self quarantine unless it's literally not possible for you to do so. You must limit the infection vectors. Even if we are successful, people will slip through the cracks.

Healthcare personnel will be unduly put at risk. Non-COVID-19 patients will not get the care they need because the hospitals cannot take care of everyone right now. ERs are already encouraging people to stay away unless absolutely necessary. Furthermore, providers for nursing homes and home health agencies are having real difficulty getting protective equipment making it harder and riskier to provide service to the senior population in these communities.

Seniors will be disproportionately afflicted by COVID-19, resulting in tragic losses. Nursing homes will not only need to ensure that they can keep the virus away, but also will have to deprive their patients from seeing their families in the interest of quarantining the facility for the benefit of the patients. This runs the risk of a social recession, increased dementia, and depression among seniors.

Populations that tend to be forgotten in crisis like these include, the homeless, orphans, prisoners, the unemployed and underemployed, immigrants / non native english speakers, those living paycheck to paycheck, small business owners trying to stay afloat, gig economy workers, truck drivers, minimum wage workers, emergency workers, the uninsured and under-insured, etc. Some of these folks will slip through the cracks. We won't fully understand how much till after we are through the worst of COVID-19.

To help some of these individuals, financially speaking at least, governments worldwide have implemented stimulus packages, including making credit available to small businesses, and are even giving their people free money to keep them afloat. Italy, froze mortgage and tax payments, in a bold move that the US will likely need to emulate.

This is a serious situation. I hope this piece gives you a glimpse of what you need to prepare for.

In the end it is best to remember we are all in this together - so when in doubt behave as if you're already an asymptomatic carrier who is infected with COVID-19. Stay home so you don't infect anyone!

Hope for the best, prepare for the worst!


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