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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.