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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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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

https://youtu.be/tPx1yqvJgf4
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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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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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What to Tell Our Kids

I am slapping a disclaimer on this one. I am far from an expert on how to educate our kids about COVID-19. I am just a dad, along with a mom, trying to figure out what our kids should know about the current state of the world and how to explain it in a way that makes sense to a couple of toddlers. Fortunately, there are a lot of great kid-friendly resources out there. And it turns out that our kids already know quite a bit. So lets not underestimate their ability to understand the situation, or their desire to help.

Fist off, kids already know that getting sick is a bad thing. Nobody likes a tummy ache. They also already know the single most important thing we can do to protect ourselves from getting sick, be it from coronavirus or any germ for that matter – WASH YOUR HANDS! And just in case anyone needs a refresher, Pinkfong has us covered (by planting that incessant earworm, more infectious than the coronavirus itself, do do doo do do…)

Another video my 3-year-old cant get enough of is this cute little animation from the WHO (no, not The Who) on how-to protect yourself from COVID-19.

Kids also already know the importance of chicken wings. Chicken wings, you ask? (Its OK, I didn’t know either). “Chicken wings” is how kids these days learn how to sneeze into their elbows. You know, like they have a chicken wing.

What about how to explain what a virus is? This is where we’ve turned to some good old fashioned Netflix. There is a really good Ask the Story Bots episode that answers the question, “How do people catch a cold?” It is a great lesson in germs, personal hygiene, and how your immune system works to kick some viral butt. More great news; the episode is free to watch on YouTube!

For the super science-loving kid (what kid isn’t), LiveScience has created an “ultimate kids guide to the new coronavirus” and an amazing infographic that I posted below, because it’s too cool not to post.

It seems the hardest part of all this for our kids to understand is why they cant go to school, see their friends, go to the playground, go bowling, etc. And this is where it gets tricky. We don’t want to frighten them, but the whole idea of not being able to leave your home is scary, even for adults. We’ve told them that stores and playgrounds are closed, and families are staying home, just to be safe. Of course, with the news constantly on in the background, our 5-year-old is quick to point out that “we know… its because of the virus.”

Maybe for some of the older kids, it might be worthwhile explaining that most children and mommies and daddies wont get too sick if they catch the virus. But that we have to be extra careful not to get our grandmas and grandpas sick. Like I said, its tricky.

I know this post has been a bit of a departure from the rest of the site, but hey, its been a long few weeks and everyone can use a little Baby Shark right now. It is a difficult situation but it also happens to be an incredible learning opportunity for everyone, kids included. After all, they may very well be the ones preventing the next pandemic. And since our kids are not in school, us parents have an even bigger role to play in teaching them about this. So lets make the most of it. Go squeeze yourself in between the kiddos on the couch and enjoy some Story Bots together.

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This is Not the Flu

Communication is key

The word pandemic just sounds scary. I mean, it literally says panic with a few letters in-between. So how do we remain calm while still appreciating the gravity of the situation? It is a delicate but crucial balance that hinges on effective communication. So far, some of the messages we’ve received haven’t been consistent or clear, the consequences of which could be dire for parts of the country.

Many downplayed the severity of COVID-19 from the start, suggesting that “it’s just the flu.” Information from other countries about who is at highest risk has been misinterpreted to mean that COVID-19 is not a concern for most people. Early data from the US paint a much different picture, with many young, healthy individuals being hospitalized. Further, considering the sheer number of people likely to contract the virus, even if the majority of cases are mild, there are still an immense number of Americans at risk for serious illness or even death. This is why COVID-19 not just the flu.

no immunity

COVID-19 is caused by a novel coronavirus, to which no person on earth, young or old, has immunity (unless already infected and recovered). Still, for many people, the symptoms (which resemble the flu) are mild enough that they resolve at home without any treatment. Some don’t have any symptoms at all. This is one of the reasons why COVID-19 spreads so quickly. Most infected people are still healthy enough to continue spreading it, out and about.

extra contagious

In addition to COVID-19 being free to infect without immunity, it is also the way the virus is structured that makes it so contagious. It is uniquely “sticky” to human cells, significantly more so than other coronaviruses like those which cause the common cold. Think about what your shoelaces look like after you’ve walked through a patch of burrs. This is what COVID-19 does in a person’s respiratory tract.

Novel Coronavirus SARS-CoV-2 (CDC) compared to a grass bur (by Zephyris)

Read: Why the Coronavirus has Been so Successful – The Atlantic

can be severe – even in healthy people

While older people and people with underlying health conditions are at heightened risk for severe disease, some people who don’t fall within these categories can also have severe disease that requires hospitalization or even results in death. It is less likely but it is still happening. Even for those who resolve at home, it can be a long and far-from-enjoyable recovery, worse than the flu.

Patients often take a turn for the worse when their immune system kicks into overdrive. It starts to attack the body’s own healthy cells in an attempt to “unstick” the virus. These “cytokine storms” are likely responsible for the severe acute respiratory syndrome that leads to the need for breathing assistance. Young and healthy individuals with strong, healthy immune systems can also be at risk for this brute force immune response. In fact, this was the reason why so many young people died during the 1918 Pandemic Flu.

Ten Times more fatal

The case fatality rate for COVID-19 is still not entirely clear, though some research estimates it could be as high as 3% or 30 in 1000. More likely, the death rate is closer to 1% or 10 in 1000. Still, the death rate for seasonal influenza is just a fraction of that with 0.1% or 1 in 1000 flu cases resulting in death.

no vaccine (YET)

For a virus to stop freely circulating in a community, enough people have to have developed an immunity to it, either by becoming infected and recovering or through vaccine-acquired immunity. When it comes to the viruses that cause COVID-19, seasonal flu, and other severe illnesses, because post-infection treatment options are limited, the objective is to prevent or significantly diminish illness through mass vaccination campaigns. The US Department of Health and Human Services along with FDA and pharmaceutical industry are trying to fast-track the development of a novel coronavirus vaccine.

conveying calm and control

So how do we stay hopeful given what we are up against? Communication is key. Is the job of health departments and government officials to deliver understandable, credible, and actionable information in a way that conveys compassion for the community and sensitivity to the challenges. Citizens deserve transparency about the plan – how it works, why it will work, and most importantly, why we all have a role to play for it to work. In return, we will all do our part.

We cant ignore the facts, we need to embrace them. We shouldn’t be giving out target dates to “reopen for business.” We need to manage expectations appropriately. As you can see, the mandate to stay home is not overblown, and it may be in our best interest for it to last another 6-10 weeks. Our goal is to draw out the spread of infection. The more we can push the peak, the more patients we can treat, the more lives we can save.

It is not just our own health we are protecting – which may not seem like a big deal if you are young and healthy. It is the health of our loved ones, our friends, and our neighbors. Nobody is immune to the virus or, especially, to its ramifications.

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No City is Immune

Although COVID-19 is an equal opportunity pathogen, there is a stark contrast in perception of and response to the threat of this highly infectious virus across areas of the United States. We see major metropolitan, densely populated cities decreeing shelter-in-place-type orders. Meanwhile, we hear of rural America questioning social distancing measures. We even see the President of the United States trying to balance an effective response while also appealing to the “less-concerned” America, tweeting:

Small cities, towns, and rural areas are not immune to COVID-19. The Governor of Louisiana, recently said,

“We have the fastest growth rate of confirmed cases in the world in the first 13 days right here in Louisiana”

Louisiana Governor John Bel Edwards

The national battle against the spread of COVID-19 could be won or lost in small cities and small towns across the country. Unchecked by social distancing, this virus will continue to infect without prejudice. But rural Americans may be at higher risk of more severe disease and worse outcomes. That is because rural communities are more often older, more likely to be obese, more likely to smoke, and more likely to be of overall poorer health. These communities also have fewer (and far between) healthcare facilities.

Whether you are a town of 1000 or a city of 10 million, no-one is immune to COVID-19 or from its rapid spread. Smaller communities may, in fact, be at higher risk of overwhelming their local healthcare systems. The result of which could be a higher fatality rate than the major metropolitan areas with the lion’s share of cases.

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