Author: Michael

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Stay the Course

The following is a transcript of my remarks made during the weekly public address of the Office of the Mayor, Bayonne, NJ – May 28, 2020

My name is Michael Rosanoff and I am an epidemiologist and public health professional proudly serving as a member of the Bayonne COVID-19 taskforce, under the Office of Emergency Management and the leadership of Mayor Davis.

I would like to take this opportunity to briefly discuss the journey that we have all been on for the last 11 weeks, since the World Health Organization declared COVID-19 a global pandemic on March 11th, and since Bayonne began implementing efforts to mitigate the spread of the coronavirus in our City.

I would like to discuss where we began, how we got to where we are today, and what we might expect over the coming weeks to months as we continue to address the pandemic in our community.

Bayonne, NJ had its first confirmed COVID-19 case on March 18th. Nearly one week earlier, any parent of a school-age child in Bayonne will know, the decision was made to preemptively close schools. This was a critically important step taken to slow the spread of the virus and to protect our children and teachers.

Shortly thereafter, restaurants were restricted to take-out only, retail stores were closed to customers, and our state’s directives to stay at home began. Essential services like grocery stores remained open, but the number of customers were limited, senior shopping hours were added, and anyone out in public was asked to stay six feet apart. Our world of “social distancing” had begun.

Why did our City and our State take these measures? The purpose was to slow the spread of the virus and “flatten the curve.” This term was used to describe how reducing our exposure to one another could reduce the rate of new COVID-19 infections, and avoid a potential tidal wave of new cases in a short period of time.

The fear was that a rapid surge in cases could overwhelm our hospital system and limit our ability to treat patients, as beds, ventilators, and personal protective equipment were all in limited supply.

Fortunately, we never got to that point in Bayonne. We certainly came close, but our front-line healthcare workers remained strong. Our community remained strong. Because we listened, stayed at home, and followed the social distancing guidelines, we were able to flatten the curve and slow the spread.

This brings us to where we are today. We are at a place where we are seeing a consistent and steady decline in the number of new COVID-19 cases and new hospital admissions. We have met criteria to begin to reopen aspects of society, but will need to do so slowly and in stages.

We should be proud of our collective commitment to slowing the spread of the virus, and be hopeful that the worst is behind us. However, we should not mistake this moment as the end of the pandemic.

While our goal has always been to slow the spread of COVID-19, we also know that it will take more work to stop the spread altogether. What we know about infectious diseases is that a certain percentage of the population needs to have immunity to the virus before we can stop its spread.

Some scientists estimate that 60-80%, or up to 8 out of 10 people, need to have immunity to COVID-19 for new infections to stop. We do not know how many people have immunity to COVID-19 today, but it is likely well under that number.

It is still unclear whether recovering from COVID-19 and having antibodies to the virus is enough to be immune from re-infection. What we do know is that the preferred way of achieving that 60-80% immunity is by finding a COVID-19 vaccine. While there are some promising clinical trials taking place, and the studies are being accelerated, a vaccine is not expected to be available before the end of 2020.

What this means is that we are not out of the woods yet. We shouldn’t be fearful but we must be mindful that the virus is still out there, it is still highly contagious, and it can still cause very serious illness for some people.

As the weather is turning nicer and society begins to re-open, it might be more difficult to adhere to the social distancing guidelines, but we must continue to do so. Though we may no longer be told to stay at home, we are still safer at home.

We must continue to maintain six feet distance from others, not only in supermarkets but at the park, or walking the Bayonne bridge, or anytime we are out in public. And research has shown that wearing a face covering does significantly reduce the spread of respiratory droplets that carry the coronavirus – so continue to wear a face covering in public, and always wear one when you may not be able to maintain six feet distance from others.

Many of us will want to visit with family and friends that we haven’t seen in weeks. The best guidance is to continue to limit your exposure to others outside of perhaps a small and select circle of trusted family and friends. Choose your small circle and stick with it. This is not the time for large gatherings.

Most importantly, we must protect our family, friends, and members of the community at highest risk of severe illness from COVID-19, including our seniors and those with other health conditions.

If we remain vigilant, we will continue to see a steady decline and plateau of new COVID cases through the summer months. But we also must prepare ourselves and our community for the possibility of a resurgence of the virus and another wave of cases, particularly as we get into fall and winter, when we will start to see cases of seasonal flu as well.

While we continue to be hopeful, we must not let our guard down. And if we do start to see a resurgence, we will be ready. Bayonne has demonstrated that, as a community, over the last 11 weeks, we will do what it takes to protect our loved ones and neighbors.

Let’s all continue to recognize the incredible work and sacrifice of our front-line essential workers and emergency personnel. And let’ remember those in our community, and around the country and world, who have lost their lives or family members to this pandemic.

Thank you again for following the guidelines. Please continue to wear a mask, wash your hands, and practice social distancing. And to stay strong as we overcome the pandemic together.

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Is Testing Telling?

It has been one of the chief criticisms of our national response to the COVID-19 pandemic – we need more testing. But what exactly does that mean and will “more testing” provide the answers we seek? Some states and local municipalities are relaxing testing restrictions and making widespread testing available to residents, with or without symptoms. But could this approach actually do more harm than good? And what exactly are we trying to accomplish with more testing? Let’s think about it for a moment.

Antigen Testing

When we hear the word “testing,” more often than not it is referring to diagnostic testing for active COVID-19 infection, aka antigen testing. It is the test to find out whether or not someone currently has COVID-19. It is the test that can be done with a quick nasal swab at a drive-up or walk-up testing site. Until recently, nearly all antigen testing was restricted to people exhibiting symptoms of COVID-19. Many testing sites required a physicians prescription. In the very early stages of the outbreak, only those with symptoms that had either been in contact with a confirmed case or have traveled to China were able to be tested. The exception to all of this has been testing for front line healthcare workers and emergency personnel, who are in regular contact with known or suspected cases.

In the early stages of the outbreak in the US, it made sense to test as many people with symptoms as possible, but we did not have the testing capacity (enough testing kits, trained personnel, testing sites, etc.) at the time. That was a major, and justified, criticism. By identifying as many cases as possible, those who tested positive, especially those with mild symptoms, could be given guidance to self-isolate, as could any others people that may have come into contact with the infected person. The ability to conduct this “contact tracing” has and continues to be a challenge as well.

But there was and remains a major limitation to symptomatic testing – it misses all of the asymptomatic or pre-symptomatic cases, which some suggest could make up more than 50% of all cases (the true number remains unclear). And these asymptomatic cases may have been the “super spreaders” in the early stages of the pandemic before social distancing measures were put in place. One proposed solution to finding asymptomatic carriers is to open testing to anyone, including asymptomatic people. But does this make sense?

Asymptomatic Testing

The problem with widespread asymptomatic testing is that it’s questionable whether it is actually informative for decision-making. An antigen test tells us one thing – do you currently have a COVID-19 infection. If the answer is yes, then that is good news for the health official who can now instruct that patient, and anyone who has been in close contact with that patient, to self-isolate. We can presumably now stop that person from further spreading the virus, whereas otherwise that person may have never even been diagnosed.

But what if that person tests negative? That person may not have the virus at the moment, but could contract the virus later on, be it that day, or that week, or that month. In fact, that person could have been exposed to the virus while waiting to be tested. We wouldn’t know. Thus, a negative test can instill a false sense of security that the person is healthy and safe, when really nothing has changed. A negative test in not especially informative.

Further, it could be a false negative test, meaning that the person has contracted the virus but it may be too early in the infection to accurately detect the virus. This is an even worse case because then that person is likely to spread it to someone else if not practicing strict social isolation guidelines.

Widespread testing can also put a major burden on the healthcare system. It requires trained personnel, personal protective equipment, testing kits, testing sites, and lab equipment. It is worth noting that during the time when testing was restricted only to symptomatic cases, most US states had a positive test rate around 50% or less. With asymptomatic testing, we will have far more negative tests, each requiring the time and resources of the healthcare system. It also has the potential to create a situation that puts healthy people in contact with infected people, while crowding healthcare facility spaces and testing sites.

Asymptomatic testing may make sense in certain situations. Health care workers and first responders who are in daily contact with potentially infected people, should be tested regularly, even in the absence of symptoms. Anyone who has been in recent contact with a known case or a person under investigation (via contact tracing) should also have access to testing without symptoms. Seniors and individuals with underlying health conditions that are at particularly high risk for severe COVID-19 disease could benefit from regular testing (if performed safely). And as we reopen aspects of society, certain types of employees like teachers and day care workers, food service employees, and maybe grocery and retail employees in constant contact with many people, should have access to regular testing.

These represent sectors of the workforce that have the potential to spread the virus widely if infected, but perhaps also represent a more manageable section of the community in terms of size, for which regular testing would be more feasible and practical. How often individuals should be tested is up for debate. But because one test can only tell us whether someone has COVID-19 at that single point in time, the more often the testing the better.

Serologic (Antibody) Testing

Serologic testing, or antibody testing, is the other type of testing that we are hearing about and it may be the type of widespread testing we actually need, though that’s not entirely clear either. Antibody testing looks for the presence of COVID-19 antibodies, which are a signal that the body produced an immune response to a COVID-19 infection. In other words, if you test positive for antibodies, you had the virus.

Based on what we know about viral immunology in general, if your body has produced antibodies to a virus, you have immunity to that virus and cannot be infected again. The problem with the novel coronavirus is that it has been around for less than 6 months and we don’t know for sure if the presence of antibodies means protection from reinfection. It is unclear if you need a certain level of antibodies to achieve immunity. And it is unclear how long that immunity may last. For these reasons, a positive antibody test may not be informative for decision-making about whether it is safe to return to work or relax stay-at-home orders.

It would, on the other hand, help us understand the prevalence of COVID-19 infection in communities, which theoretically could help predict future infection rates. But the latter still requires us to assume that those who have been infected can no longer get or spread the virus in the future.

Currently, antibody testing requires a blood draw (and a trained phlebotomist), which is more invasive and resource intensive than a nasal swap or finger stick. So it is not as easy as testing for active infections. Some commercial labs have made antibody testing available to the general public with and without a doctors prescription, though it is unclear how much these test will cost or if they are covered by health insurance under the CARES Act. More importantly, it is unclear how reliable these tests are. How specific are they to identifying COVID-19 antibodies versus antibodies to other types of cornavirus?

Testing (alone) may not provide all the answers

All in all, antibody testing at this time may not be informative for decision making about when it is safe to return to society. Though it may be the key to safely re-opening communities in the future, should we confirm that the presence of antibodies means immunity. As for widespread asymptomatic antigen testing, it could cause more harm than good, putting a burden on the healthcare system while putting people at risk of exposure, or worse, instilling a false sense of security. And unless we can test nearly everyone, and test everyone on a near weekly basis, and conduct contact tracing on every positive case, then widespread testing just doesn’t make sense.

At the moment, “more testing” alone may not necessarily be the right solution if we cant act on test results. Increased testing has to be done strategically and consistently. It has to be accompanied by the appropriate follow-up including contact tracing and with effective communication to patients about what test results mean and what they don’t mean.

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A Practical Approach

We’ve all been racking our brains trying to figure out when and how it will be safe to relax the stay-at-home directives and begin our slow return to normal. In our city, it appears our COVID-19 infection rate and hospital admission rate has crested and now plateaued over the last 10 days. We came close, but never exceeded hospital capacity in terms of beds, ventilators, or personal protective equipment. Our social distancing measures did their job. The fear now is that relaxing those measures too soon could send the infection rate back up.

The problem in answering the question of when we can re-open is that there simply isn’t a clear answer. There is no quantitative measure of readiness. We’ve checked one box – the number of new infections are under control.

Maybe we need to turn the question around. When will we – you and I – feel safe going back work? Riding mass transit? Sending our kids to school? Eating at a restaurant? The answer to those questions different. It is when the risk of infection is slim to none. Fortunately, there are ways to quantitatively measure that and at least estimate the risk. But we first need to know who has had COVID-19.

In theory (but still a BIG question mark), people with COVID-19 antibodies should have immunity to the virus and should be free to roam about the world without fear of becoming infected or spreading it to anyone else. Unless you were tested, clinically diagnosed, and have recovered from COVID-19, there is no way of knowing if you have antibodies. That is unless you receive an antibody test.

Currently, there is no widespread access to these tests. Some community testing has taken place as part of research. One study, touted by the Governor of New York today, showed that as many as 14% of New York residents have COVID-19 antibodies. Until we know who and how many people in the wider community are immune, we can never truly gauge just how safe it is to return to the outside world.

This is where a practical approach is needed, and a practical solution may exist. There may be an opportunity for widespread antibody testing, by utilizing a network of blood testing sites that already exists in communities across the country right now. The American Red Cross.

You see, the Red Cross is the non-profit organization that provides disaster relief and coordinates blood donation campaigns across the country in preparation for those disaster situations. It provides US hospitals with about half of the nation’s blood supply. If you’ve ever seen a poster for a blood drive, the Red Cross was probably involved. The have staff, volunteers, and donation sites in every state if not every city.

The Red Cross is also the organization currently taking the lead in identifying donors as part of its COVID-19 convalescent plasma program. As I mentioned earlier, individuals who have recovered from COVID-19 have antibodies in their blood that not only make them resistant to future infections, but their blood can also be used as a treatment for other patients with severe COVID-19 symptoms. There is now a major campaign to recruit recovered COVID-19 patients (with a documented positive COVID-19 test) as plasma donors, with the potential to save many lives as the coronavirus crisis continues. The challenge has been identifying enough donors.

Another challenge being faced by the Red Cross, and by hospitals around the country, is a severe blood shortage caused by COVID-19. Many blood drives have been canceled and donors are canceling scheduled donations due to stay-at-home directives.

There is an opportunity to address three major issues by utilizing The American Red Cross: 1) identifying plasma donors for COVID-19 treatment; 2) increasing donations and the nation’s blood supply; and 3) widespread community testing for COVID-19 antibodies.

This would be a nationwide campaign by the American Red Cross – a national blood drive, so to speak – with the promise of testing never-diagnosed, even asymptomatic donors for active COVID-19 virus or COVID-19 antibodies. The Red Cross has to test these blood samples for pathogens anyway before they are made available to patients. In the process, we would also be identifying much needed convalescent plasma donors and providing a much needed boost to the US blood supply.

It’s a win-win-win-win. We get tested. The Red Cross gets blood. Hospitals get plasma. Public health officials get the elusive COVID-19 data we need to re-open the country.

The major question is capacity. Does the Red Cross have enough personnel, supplies, testing kits, donation sites, etc. to manage the donor “demand” while adhering to social distancing guidelines? By-appointment-only donation appointments could help mitiage this. Also, many community locations could be utilized or re-purposed for blood drives. If my old high school auditorium could handle it, then so can many other places. This makes the testing process more practical and way more scalable than if it required a doctors appointment and an in-office blood draw. (Don’t forget medical insurance).

The US is fortunate to have an organizational like The American Red Cross, with blood drawing and testing infrastructure in place in nearly every community in the country. This presents a unique opportunity to tap into this supply (no vampire pun intended) to help bring our country closer to re-opening, by generating real-world quantitative data on infection risk in our local communities. And along with blood type, the Red Cross could include COVID-19 antibody status right on our donor cards.

There is still a lot we don’t yet know about COVID-19 immunity, like whether the presence of antibodies means there is no longer a risk of re-infection. Or if there needs to be a certain amount of antibody to achieve immunity. Or how long immunity of any kind actually lasts. There are also questions about the reliability of antibody tests – like are they specific to COVID-19 and not capturing the presence of other coronovirus antibodies? Thus, at this moment in time, antibody test results are not informative for determining individual risk or for decision making on the scale of communities looking for indicators of when it will be safe to “reopen.”

For more on the subject of testing and its implications, see my post:

Is Testing Telling?
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What’s Next?

Our situation is improving. Recent updates to the modeling that most health and government officials are using to gauge the pandemic suggest that we are flattening the curve. Growth of new cases and hospital admissions appear to be coming down, according to the respective Governors of New York and New Jersey. There is a light at the end of the tunnel. Whether it’s daylight or another COVID-19 freight train could depend on our decisions and actions over the next few weeks to months. What comes next may be up to us.

If we are at peak, close to the peak, or perhaps even past the peak, what can we expect the COVID-19 situation to look like over the next few weeks and months? When can we start getting back to normal (or at least our new normal)? The answer is not entirely clear, but the models are giving us an idea. And a choice.

If we relax social distancing all at once…

We could see a resurgence of COVID-19 infections, perhaps close in magnitude to that of the first wave of cases. Why? Because, as far as we know, only a fraction of the population has been exposed to the virus and has immunity. Some recent data suggest that, on average, one individual with COVID-19 infects between five and six other people. This means that as more than 80% of the entire population would need immunity to COVID-19 to actually stop the spread (via herd immunity). In other words, 8 out of 10 people would need to become infected (or vaccinated, but a vaccine is probably more than a year away).

The point here is that we cant simply “reopen the US for business” all at once, or else we risk ending up back where we started. Though we have certainly learned a lot about COVID-19 and our hospitals will likely be better prepared, we do not want to risk flooding the healthcare system and putting more lives at risk.

Even if we extend the stay-at-home directive for another 30 days, but then completely remove it along with the other social distancing measures, we risk another wave of cases – a second peak – just the same.

If we relax social distancing over time…

We could settle into a much lower plateau of new infections – a steady flow of new COVID-19 cases spread out over a longer time period. If it is true that over 80% of everyone would need to become infected, then we would want that process to take as long as possible, with as few peaks (rapid influxes of new cases) as possible.

A projection from the Federal COVID-19 Data & Analytics Task Force suggests that if we maintain a “steady state” of partially relaxed social distancing, we could achieve this steady state of infections. This involves keeping schools closed through the school year (through summer), and at least 25% of employees still telecommuting, along with other social distancing measures, perhaps like limiting the number patrons at restaurants and the size of public gatherings.

This leads to arguably the most important question we need answered.

Who can safely leave their home?

One of the reasons why we don’t know when we will be able to return to normal is because we simply have no idea who and how many of us have been infected by and developed immunity to COVID-19. The game-changer in determining how we, as a country, will recover from this pandemic will be the availability of antibody testing.

After someone has been infected with the coronavirus and recovered, their body has antibodies to the virus that can be identified in a test. If someone tests positive for coronavirus antibodies, they are presumably immune to the virus. (I say presumably because we are not yet entirely sure about risk of re-infection, particularly for patients who had very mild cases the first time around).

As we begin to relax social distancing and return back to normal life, those who have immunity to COVID-19 would be able to safely leave their home without risk of contracting or spreading coronavirus. Unless you were tested, confirmed to have COVID-19, and have since recovered (per CDC guidelines), you have no idea whether or not you’ve had the virus. Remember, some estimates say up to 50% of cases have no symptoms at all whatsoever. It is possible, if not probably, that for every case that has been officially diagnosed, there are 10 more cases that were never diagnosed and resolved without any medical attention whatsoever.

With this in mind, perhaps younger, generally healthy people could return to work even without immunity because of the lower risk of severe symptoms. The problem is that we don’t know for sure. Early data show that younger Americans with COVID-19 are still being hospitalized. Also a major problem is that asymptomatic carriers could spread the virus to older individuals or others with underlying health conditions. So until we have access to an antibody test, we are essentially blindly making decisions about when and how to relax social distancing.

Not out of the woods

And we may not be for a while.

Social distancing is having a major impact on slowing the spread. However, this does not mean that COVID-19 has stopped spreading. Nor will it stop spreading just because we pass the peak. Case numbers continue to rise. Lives are still being lost.

Some of us will be home through May. Possibly into June. Possibly again come fall. There is some evidence that there could be a seasonal resurgence of COVID-19 when the weather cools.

While we may be able to begin relaxing social distancing measures and begin returning to some semblance of normal life as early as next month, those decisions and policies will likely be state and city specific. Population density does influence the spread of the virus. Metropolitan areas will likely need to very slowly relax the stay-at-home and social distancing directives over a longer period of time.

A new normal

Face masks? No handshakes? No fans at sporting events? Will we think twice about going to dinner and a movie? One thing we can be sure of is that, regardless of when we start to return to the outside world, our world will look a lot different for a long time, if not forever.

So where do we go from here? For now, we keep doing what we are doing. We stay home. But when we start to return to normal – our new normal – we need to do it cautiously and wisely. Ideally we will make those critical decisions based on evidence and testing, and not just based on days on a calendar.

UPDATE: 4/11/20 10:30AM – New York City has announced that public schools will be closed for the remainder of the school year.

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Masking the Risk

We are approaching 400 identified cases here in our city, which may still only represent about 20% of the actual number. We may be nearing the peak of the COVID-19 crisis and, rightfully so, our stay-at-home directive remains in place. Yet, my household is out of goldfish crackers and I need to replenish supplies before my kids revolt. You may be in a similar predicament. So how do we stay safe while making that essential shopping run?

We lasted two weeks (which is pretty good in my opinion) but I had to leave the safety of home to restock on groceries over the weekend. A few days earlier, the CDC released new guidance on the public use of face coverings. The Governor of New Jersey followed suit, requiring all retail store customers to wear a face covering while shopping. So to keep myself safe – in addition to distancing from other shoppers and not touching my face – I donned a medical-grade face mask that I fortunately had at home.

Why face coverings?

Lets start with the why. Why should we wear a face covering? First, notice I am saying face covering and not mask. The CDC was intentional in saying this in its guidelines. The reason is because we are already experiencing a shortage of medical grade masks in many places around the country. And in the worst possible places – hospitals. Our front-line healthcare providers are the ones who need these masks the most. I am not just talking about the N95 mask, which is the “top-of-the-line” medical respirator used to filter 95% of all airborne particles. I am also talking about the “run-of-the-mill” surgical masks. The CDC recommends wearing face “coverings” as opposed to “masks” to keep the already limited supply from dwindling even further.

Wait, so any old scarf will do the job? These is where we need some science. Those run-of-the-mill surgical masks don’t filter airborne particles. Instead they keep fluid droplets from coming in, and more importantly, from coming out of the person wearing the mask. Because COVID-19 is transmitted by liquid droplets, wearing any fabric face covering – be it a surgical mask or a bandanna – will keep those fluid droplets from getting into – or out of – the nose and mouth. Many COVID-19 spreaders are either asymptomatic or pre-symptomatic, and those individuals can prevent spreading the virus by breathing through a face covering.

CDC: Understanding the difference between a surgical mask and an N95 respirator
This is a good thing, right?

Yes, and no. While wearing a face covering can reduce the likelihood of spreading the virus in public, it can also provide a false sense of security. In a way, wearing a mask can mask the true risk.

Masks do not replace social distancing. If you need to leave home, one of the best preventative measures is to stay away from people. It sounds rude, but its not. It’s rude to invade someone’s 6 foot force field. Just because you have a face mask does not mean you can relax the other social distancing measures.

Whats worse, I fear, is that the face covering recommendatios could actually backfire. What I saw at the grocery store was alarming. While it was great to see nearly everyone wearing a face covering, nearly everyone I saw was also constantly fidgeting with those face coverings.

The CDC is recommending that we make our own face covering. These homemade, make shift masks can be bulky, uncomfortable, and/or really hot, especially indoors, especially if you are using a scarf. Anyone not used to wearing a mask, even a medical-grade mask, might be tempted to adjust and play with the mask to get a better fit. Each time you touch your mask, you risk bringing the virus to your face from your hands, even if you are wearing gloves.

Unmasking the issues

The COVID-19 pandemic has unmasked a number of issues with regard to the use of face masks in the US. Ideally, everyone would already own a medical-grade mask, know how to use it, and be comfortable using it. Unfortunately, none of these are true for the average American.

Much of this stems from our fear of masks in public. Mask wearing is highly stigmatized in the US. Here, someone wearing a mask invokes fear. In many Asian cultures and countries, masks are worn regularly to prevent the spread of disease. A person who is ill wears a mask out of respect for others, as a precaution. If we had the same cultural understanding here, we would be more likely to own and be comfortable using masks. We might also be avoiding the current crushing demand for masks, weighing heavily on the healthcare system.

Instead, our fear of masks, our lack of understanding about masks, and our limited supply of masks have left us unprepared and scrambling. Not just individuals scrambling to create face coverings, but federal agencies scrambling to provide guidelines and hope that people will change their long-standing behaviors. Hopefully, now and after the COVID-19 crisis, masks are no longer seen as weird. They are seen as a courtesy. We should expect – and hope – that masks become a part of our new normal. They are already becoming the new must-post social media selfie. #covidmask

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Our Mental Health

Has it happened to you too? More than once in the last few weeks, I’ve woken up in the middle of the night questioning whether or not all of this is real. Is there really a pandemic virus claiming tens of thousands of lives around the world? It’s like a movie plot. Scratch that. It IS a movie plot. I’ve seen it. And I’ve seen it again. (I also read it when I was a kid and I think that’s what got me interested in public health in the first place).

Who would have though that something like the COVID-19 outbreak is even possible in this day and age, given our advancements in medicine and knowhow. Yet here we are. Confined to our homes. Watching the numbers rise. It’s difficult to comprehend. Even for an epidemiologist.

I never thought, when studying in school, that I would one day be living through a communicable disease pandemic. That was something for the history books. Or maybe the rare and short-lived emergence of something like Zika or swine flu. In fact, I’ve made my career mostly as a non-communicable disease epidemiologist, focusing primarily on mental health.

If I’ve learned one thing, however, it’s that physical health and mental health are inextricable intertwined. I fear we will see this play out loud and clear with the COVID-19 crisis. This infectious disease pandemic could result in one of the worst mental health pandemics in history.

Fear and anxiety

One thing this virus is particularly good at is scaring people. The endless media coverage certainly contributes to that, but many news outlets and health officials are simply telling it like it is. It is a frightening virus. It is highly contagious and has the potential to be fatal. This makes us fearful and anxious. We are concerned about our health and the health of our loved ones.

Fear itself is also contagious. People can become fearful of one another in times of uncertainty. COVID-19 has led to an outbreak of stigma and prejudice, mainly aimed at those of Asian ethnicity due to virus’ origin in China and some people calling it the “Chinese” virus. Even wearing masks in public has been highly stigmatized and can be anxiety provoking, (though that may change with the CDC’s new guidance).

How do we overcome fear? With the the facts. We know how to protect ourselves. We know how to slow the spread. And we are learning how to treat COVID-19 and prevent it from spreading in the future.

Social distancing and isolation

Part of our new reality is distance. Distance from the person in front of you at the grocery store. Distance from your neighbors next door. Distance from your family in another state. It is difficult for many to simply cut-off their social networks (the real-life ones). Having close friends and family is known to promote better overall health. Social isolation is known to have the opposite effect, particularly on our mental health.

The good news is that we are all just a video call away. It’s not the same as grabbing drinks with friends or dinner with the family, but video chat happy hours can be fun too.

Loss and bereavement

Millions of Americans may suffer the loss of a loved-one over the course of this pandemic. Worse, many individuals may not be able to mourn appropriately, due to social distancing. We are hearing heartbreaking stories of so many who have lost someone to COVID-19, who were unable to be by their bedside. Some people who may have been healthy just a few weeks ago, have succumbed to the virus. This is sad and can be shocking, especially for a close relative. Death is difficult and the grieving process can be complicated; made even more complicated by our current situation.

If you or someone you know is dealing with a loss, the American Psychological Association has provided guidance on grief amidst COVID-19.

Stress and depression

All of these experiences and perceptions can feed our anxiety and lead to stress. Chronic stress can have serious mental health consequences. It can lead to substance abuse. It can lead to major depression. It can provoke thoughts of suicide. Individuals with preexisting mental health conditions are at even higher risk.

Chronic stress can also lead to inflammation in the body which can negatively impact our overall health and weaken our immune system. This, in turn, can put us at greater risk of severe COVID-19 symptoms and other conditions like cardiovascular disease.

Exercise and meditation are two at-home ways to address and overcome stress. Headspace is offering a free “weathering the storm” meditation and movement program for anyone struggling.

Lasting impact

Unfortunately, we are only about a month into this new reality, the effects of which may be felt for many more months ahead. The recovery process will be difficult for many. On top of the growing numbers of cases and deaths, the severe economic downturn due to COVID-19 has led to a record-breaking loss of jobs. Our children have been out of school for a month and may be out for the remainder of the school year. We may be able to protect our kids from the virus, but how do we protect them from the emotional and psychological challenges they may be experiencing. And how will this experience shape our future generations?

What do we tell our kids about COVID-19? Here are some ideas.

Mind your mind

Never has it been more important to take care of our health. We must treat mental health as seriously as we are treating our physical health. Now and always. There is no health without mental health. Don’t ignore it if having difficulty sleeping. If you need help, reach out to someone. Just because you are home doesn’t mean you are alone. If you are struggling with a mental health condition, be in touch with your primary physician, and have a plan should you need urgent attention.

Even if you are coping well, someone you know may be having a tough time. We can still be there without being there, so stay in touch with your friends and loved ones. Don’t forget, we are all in this together.

The CDC has put together an excellent resource focused on mental health and coping. It includes information on reducing stigma and stopping the spread of misinformation. It also provides tips on how to care for the emotional well-being of children.

visit the CDC Stress and coping page
If you are are experiencing thoughts of suicide,
contact the National Suicide Prevention Lifeline

1-800-273-8255

Text “HOME” to 741741 to chat with a crisis counselor
Connect with a counselor over Facebook Messenger
Crisis Text Line: How to Handle Coronavirus
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Communities Updates

Local Update

This post is an update on our local situation and some of the challenges we are experiencing as the number of COVID-19 cases climbs. Other communities around the country may be experiencing similar challenges now, or can anticipate and prepare for such challenges in the coming weeks. While our community had considered many of these issues, we also hoped that social distancing measures would have made a greater impact on slowing the rapidly approaching peak in new cases and new hospitalizations.

Our city now has 240 test-confirmed COVID-19 cases. Currently, only symptomatic individuals with at minimum a fever and cough are eligible for testing, as testing kits are limited. We are most certainly under-identifying COVID-19 cases. Yet, our hospital system is still quickly becoming overburdened with the cases we are identifying. Our hospitals are beginning to approach capacity.

The general escalation of the COVID-19 situation in our city, and in others around the country, has been as follows:

Hospital beds are filling up.
ICU beds are filling up even faster. They are far fewer in number and patients who need ICU attention are occupying those beds longer.
The main solution has been to re-purpose other areas of the hospital to serve as a temporary ICU. Entire floors of hospitals or entire hospitals themselves are being restricted to COVID-19 patients only as a way to reduce the chance of spread. Temporary non-COVID areas are being set up, in some cases as tents outside of hospitals. Temporary field hospitals are being set-up by the State or by FEMA as part of the federal response.

Hospital equipment and supplies are running low.
Ventilators, which serve as the primary treatment for the most severe cases of respiratory distress, are extremely limited. Personal protective equipment like masks and gowns that health care providers and hospital staff use to protect themselves and other patients are in limited supply. Testing kits are still in limited supply. Requests have been made to the State and Federal Government for additional supplies. Communities have been asked to support local hospitals through the donation of medical grade masks and gowns. The American Red Cross is requesting blood donors to address shortages (You can find out if you are eligible to donate here).

Healthcare workers themselves are in limited supply.
Long hours, a steady influx of admissions, a growing number of inpatients, and, sadly, a growing number of deaths from COVID-19 all weigh heavily on our front-line healthcare workers. In addition, should a healthcare practitioner experience symptoms and/or test positive for COVID-19, they are no longer able to treat patients and that creates a gap in staffing coverage at the hospital for an extended period of time. The shortage of providers presents one of the biggest challenges of this crisis. Cities and states are expediting the training and graduation of medical students and nursing students, allowing doctors to come out of retirement to practice, and requesting any that any licensed healthcare provider join the effort.

The same challenges extend to our first responders.
Police, fire, and EMS personnel are similarly experiencing shortages of supplies including personal protective equipment. The vast majority of reports are COVID-19 related and response to those requires proper precautions including the use of this protective gear. In addition, vehicles – police cars, fire trucks, and ambulances – and stations need to be properly cleaned at increased intervals, which requires resources and personnel. First responders, too, are falling ill with COVID-19, requiring time-off from work and creating additional stress on the emergency response system.

All of this takes a toll on our front-line workers.
This is, no doubt, a difficult time for everyone. A great amount of that burden is being carried by our healthcare workers and emergency services personnel. Lets make sure we take a moment to appreciate their selfless commitment to our health and safety. The best way we can do that is to continue to adhere to social distancing measures. Our stay-at-home directives are in place to protect them as much as they are to protect ourselves.

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Perspectives Research

Underlying Conditions

Our city today surpassed 170 identified COVID-19 cases. Regretfully, 7 patients have died. We continue to see here, and around the country, that certain individuals have a higher risk of severe illness and death from COVID-19. Most of those who have been lost were over the age of 65 and/or had underlying conditions.

In this post, my goal is to help decipher what is meant by “underlying conditions” and why people that have them also have the highest risk for the worst COVID-19 outcomes. My second goal is to call attention to the other underlying conditions that are being overlooked.

Underlying conditions, simply put, refer to other diseases and disorders that are sort of operating in the background, before a person ever becomes infected with coronavirus. [FYI, you may also hear underlying health conditions referred to as co-morbid or co-occurring conditions]. People with underlying health conditions are of generally worse health and are, thus, at a distinct disadvantage when it comes to overcoming COVID-19. Starting behind the eight-ball, so to speak.

In addition to old age (which typically brings underlying health conditions along with it), research out of China and Italy has showed us that some underlying health conditions are independent risk factors (irrespective of age) for severe COVID-19-related outcomes including hospitalization, need for intensive care, and death. Just this week, the Centers for Disease Control released the first US data on the link between underlying conditions and severe COVID-19-associated outcomes.

The CDC looked at a long list of underlying health conditions including lung disease (asthma, COPD, and emphysema), diabetes, cardiovascular disease, kidney disease, liver disease, immuno-compromised conditions, and neurological and developmental disorders, among others. They even took it a step further to include some of the more general risk factors for severe respiratory infections – factors like smoking and even pregnancy (think gestational diabetes). Here are the main findings:

Key Study Findings

71% of hospitalizations and 78% of COVID-19 patients admitted to the ICU had one or more underlying health condition.

By comparison, just 27% of COVID-19 cases who were not hospitalized had an underlying health condition.

In general, cases with underlying health conditions were significantly more likely to be hospitalized and more likely to be admitted to an ICU than those without.

Among the 184 deaths included in this analysis, 94% of deaths were patients with underlying health conditions.

The most commonly reported underlying health conditions were diabetes (10.9%), chronic lung disease (9.2%), and cardiovascular disease (9.0%).

It is important to note that this information may not be telling the whole story. First, of the 122,000+ plus US cases identified at the time of this report, information on underlying health conditions was only available for 7,000 (or 5.8%) of them. These small numbers, and the fact that we are still early in the spread of COVID-19 in the US, limit our ability to generalize these findings to the US as a whole. Only the presence or absence of these conditions was known and not their severity or whether or not they were being treated, both of which may have an impact on COVID-19 outcomes.

Still, the research all seems to agree that people with underlying health conditions are at significantly increased risk of more severe COVID-19 outcomes. Of major concern to us is that so many Americans have health issues that are tied to these underlying conditions. Things like obesity, which is linked to diabetes and cardiovascular disease; and smoking, which is tied to lung disease. Even asthma, which impacts about 8% of Americans, could complicate respiratory infections. These too should also be considered risk factors for severe COVID-19 illness. And this is where we get to the other underlying conditions.

The other underlying conditions

All of the other health problems that we had before COVID-19 didn’t just disappear once COVID-19 showed up. People are still having heart attacks. Still getting cancer. Still struggling with mental health and substance abuse problems. Perhaps even more so than ever. In fact, all of these conditions are likely to be exacerbated by the current COVID-19 pandemic.

Limited access to healthy food options; limited physical activity; increased exposure to poor indoor air quality; psychological stress, anxiety, and depression from the general state of affairs, social isolation, or the loss of a loved one. All can lead to poorer health and all are happening right now. At the same time, we may think twice before leaving the house to see our doctors. Or worse, because of the strains on our healthcare system, there may not be a bed for a heart attack patient or a doctor to mend a broken bone at the hospital.

Health inequities are also being exacerbated with some of our most vulnerable and disadvantaged citizens being impacted the most by this pandemic – by the virus and its economic consequences. These are the underlying conditions of our health and of our society that have been operating in the background since long before we were ever exposed to COVID-19. Now, they may be spreading, even faster than the virus.

Study: Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020. MMWR Morb Mortal Wkly Rep. ePub: 31 March 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6913e2external icon

UPDATE (4/2/20): NYC released a data summary of underlying conditions among COVID-19 deaths to date. Over 98% (994/1012) of all NYC deaths (with confirmed health history) had one or more underlying condition. About 75% (1012/1374) of NYC COVID-19 deaths have confirmed health history (25% still pending).

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Projections

Peaking Too Soon

My apologies for constantly bombarding you with numbers, and models, and projections (oh, my). But 1) I am an epidemiologist and it is my job, and 2) major media outlets are running with the story of a new COVID-19 projection that deserves your attention.

Released alongside a preprint publication yesterday, the Institute for Health Metrics and Evaluation at the University of Washington has developed a data visualization tool that projects national and state-by-state COVID-19 curves. By utilizing case, hospitalization, and death rate data from across the US, the tool projects when the peak of the curve will occur. Even with the social distancing measures of all 50 states factored into the model, it predicts that the US will reach the peak of hospital utilization and the peak number of daily COVID-19 deaths within two weeks, on April 15th.

US Projected COVID-19 Peak: April 15th

Based on the model at the peak of hospital resource use, the US as a whole may be short more than 50,000 hospital beds including a shortfall of more than 13,000 ICU beds.

The number of COVID-19 deaths per day in the US is estimated to reach 2,200 (with a possible range of 1,100 to 3,300) at peak on April 15th.

In total, the model predicts just over 81,000 COVID-19 deaths in the US by June 1st, with a possible range anywhere from 36,500 to 144,500 deaths.

To me, these models are interesting but they are still only models at the end of the day. They are projections of what may occur, but they are not necessarily predictive, and certainly not prescriptive, of what will occur in the US.

What I find more informative about these models are some of the state specific projections – not so much the numbers but rather the timing. Take my state, New Jersey, for example. It would seem we are ahead of the national curve, and not in a good way.

NJ Projected COVID-19 Peak: April 8th

The model predicts the peak of hospital resource use to occur in approximately one week, on April 8th.

Statewide, we will be very close to capacity in terms of overall beds, and almost at double the capacity of ICU beds.

The number of deaths per day peaks by April 9th at 90, with a range of 50-125 deaths per day.

By around May 1st, New Jersey total deaths hits its plateau (a full month ahead of the US as a whole).

Statewide, total deaths are projected to be between 1000-2600, with 1850 being the point estimate.

It would appear that New Jersey (and neighboring New York) hit peak a week earlier than the nation reaches its peak. It is certainly possible, though health and government officials around here have certainly been hoping to push the peak out at least a few more weeks longer than the seven days this model is giving us.

Just as states across the US have different curves and timing, it is probably that cities and communities within states also have different curves. These projections are based on state-wide data and are not specific to any one part of the state. Our city implemented social distancing measures about one week before there were state-wide mandates. Yet, our city is more densely populated and closer to the NYC epicenter than other parts of the state.

I wish to reiterate that these mathematical models are imperfect. They are based on current evidence, which is limited, and are not necessarily indicative of the actual situation. We already know that we are under-identifying and underestimating total cases. However, we should still do our best to prepare for a sooner-than-anticipated peak.

It is also unlikely that COVID-19 spread will simply level-off around May 1st in New Jersey or June 1st nationwide. As we begin to relax social distancing measures, the spread of COVID-19 can be expected to continue, but hopefully at a much lesser rate. In addition, a possible seasonal effect on COVID-19 transmission could bring us a resurgence in the winter months, especially if all social distancing measures have been removed.

Explore the Institute for Health Metrics COVID-19 Projection Tool
COVID-19 Projections

Note that in these visualizations, the dotted curves represent the single point estimates. The large swath of color surrounding those lines depicts the wide range of possibilities surrounding that estimate.

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Planning Research

Summer Reprieve?

A fascinating new study suggests that the transmission of COVID-19 may fluctuate seasonally, and that the spread may slow down as temperatures rise. On the flip side, we may see a resurgence of the virus heading into fall and winter.

Key Study Findings
  • Warmer temperatures by 1°C (1.8°F) reduced the transmission rate of COVID-19 by 13%.
  • Changes in temperature from March to July 2020 may lead to a 43% decrease in COVID-19 transmission in Northern Hemisphere countries like the US.
  • Southern Hemisphere countries may see a 71% increase in transmission during the same period.
  • By winter 2021, the US may see a resurgence of COVID-19 with a 59% increase in transmission from the current (March 2020) rate.
  • Due to the potential seasonality of COVID-19, northern countries like the US may have a window of opportunity over the summer months to recover and to prepare for a possible resurgence in winter.

The study, posted yesterday as a preprint (ahead of being accepted for publication), found that higher temperatures decreased the number of new COVID-19 cases in a community. The authors looked at data from 134 countries based on 166,686 COVID-19 cases diagnosed between January 22 and March 15, 2020. They found an average decrease in transmission rate (the number of new cases) across all countries was 13% for every 1°C (1.8°F) increase in temperature. This drop in transmission can have a major impact on total case numbers, particularity in areas currently suffering from a high rate of spread, like New York and other major US cities.

By modeling these findings out further, using projected temperature changes from April 2020 through January 2021, the authors predicted a 43% decrease in COVID-19 transmission across the Northern Hemisphere by July 2020 compared to today. Because the Southern Hemisphere is heading into its winter months, the authors project a 71% increase in new cases over the next 3-4 months – an alarming finding that should be noted by health officials in Southern Hemisphere countries.

As a warning to the US and other countries of the Northern Hemisphere, the study also reported a possible resurgence of COVID-19 by winter, with a 59% higher transmission rate in January 2021 compared to the rate today. This means that while we may experience a period of recovery over the summer months, we should also take that time to prepare for the next potential wave of cases. We may continue to see this seasonal ebb and flow of cases until we either reach a critical threshold for herd (community) immunity, or we have a COVID-19 vaccine, which most believe is 12-18 months away at best.

So why does temperature have anything to do with how a virus spreads? There are a number of possible mechanisms including temperature playing a role in attenuating (weakening) the virus itself. Other possibilities are that warmer temperatures encourage outdoor activities, which naturally results in more social distancing versus when people are confined to indoor spaces and are in close proximity to one another. Also people are generally healthier in the warmer months, when other seasonal illnesses are less of a threat.

This research provides clues as to whether we can expect the transmission of COVID-19 to shift as temperatures shift around the globe. However, these projections are based on early case numbers, most of which were concentrated in Europe and Asia. The authors did account for differences across countries (and regions within countries) in population density and health system capacity including the amount of COVID-19 testing, and still saw the relationship with temperature.

We can expect to learn a great deal more about the seasonality of COVID-19 as more cases are identified and as temperatures change. The authors suspect we may eventually see an even stronger impact of temperature on transmission. We may not know for sure until it happens. Until then, countries should continue to respond to the COVID-19 threat at hand. We can hope for a summer reprieve, but must also consider a possible resurgence come cooler months. Countries heading into the winter now should be aware of the potential for an increase in transmission of COVID-19.

Study: Tamma Carletonk and Kyle C. Meng. Causal empirical estimates suggest COVID-19 transmission rates are highly seasonal. medRxiv preprint doi: https://doi.org/10.1101/2020.03.26.20044420.

Accessed March 30, 2020.

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