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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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From One to One Hundred

Our city surpassed 100 confirmed COVID-19 cases over the weekend. Most individuals are recovering at home under isolation guidelines. About a quarter of those affected are currently under care at area hospitals. There are still a number of potential-cases (persons under investigation) awaiting test results that have been admitted to the hospital with severe symptoms. Two of our city’s residents have, sadly, died due to the virus.

There are a few considerations that I would like to bring to your attention while trying to make sense of these numbers and the numbers around the country.

The influx of testing is revealing an influx of cases.

I mentioned elsewhere, as testing becomes more available, we will naturally identify more cases. The initial influx obscures our ability to know where we are on the curve, and it is not an accurate indicator of whether or not we are successfully flattening that curve. While it is disheartening to see the numbers grow, do not be discouraged.

The early cases are more likely to have more severe symptoms.

Not everyone is eligible for testing at the moment, as test kits and laboratory capacity are still limited. In these early stages, only people with symptoms and a prescription from a physician are eligible. For this reason, those with most concerning symptoms are the most likely to appear at hospitals or testing centers. This skews the numbers, particularly the rate of hospital admissions.

The early case fatality rate will appear higher than it really is.

The early case fatality numbers are not accurate. It will seem as though a higher percentage of COVID-19 patients are dying than we expected. The reason is because we do not have an accurate denominator to calculate the correct rate. Not all cases have been identified yet, nor has enough time passed for us to know the fate of those cases that have been identified. And again, those early confirmed cases are more likely to have severe symptoms and, as a result, worse outcomes.

Pay attention to the hospital admissions rate.

Hospital admissions, mainly the change in admissions over time, will be the true measure of where we are on the curve and how well we are doing to flatten it. We want to see the day-to-day change in number of new COVID-19 hospital admissions to be flat or, ideally, decreasing over time. Rapid increases in this number is what we want to avoid most.

COVID-19 is still spreading.

Regardless of why, the number of COVID-19 cases is increasing. In our city, in your city, around the country, and around the world. These numbers still only represent a fraction of current and future cases.

Lives will be saved or lost depending on whether hospitals and staff have the ability – the space, the time, the equipment – to care for those who need it most. This also means the ability for healthcare providers and first responders to protect and care for themselves.

This is where you and I staying in our houses becomes so important. Stay home. Slow the spread. Save lives.

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The Real Number

Less than once week ago, we had our first local case. Today we have our 8th. Most have mild symptoms being monitored at home. Relatively speaking, our community is faring well. Especially when we need only look just across the river to find nearly 15,000 cases and the epicenter of the COVID-19 crisis in our country.

But the question remains, are we seeing the real picture here? Do these numbers – be it 8 or 15,000 – reflect the true number of COVID-19 cases in our communities. Not to sound alarming, but the answer is most certainly no.

First, why the rapid uptick in cases in such a short period of time? The numbers in our community are too small to draw conclusions from, but lets look at the country as a whole. As of writing this post, the US has just over 52,000 confirmed cases. 7 days ago, that number was 12,000. That means we are seeing cases double every 3.5 days. However, one thing we have learned from COVID-19 research and modeling is that without any social distancing whatsoever, the number of cases is expected to double every 6 days. So what’s happening here?

TESTING INFLUENCES THE NUMBER

Quite simply, look and ye shall find. With the availability of more widespread testing and the growing number of Americans being tested, we are going to find more cases. This is a major driver behind the faster than expected uptick. And we can expect the numbers to continue to rise. This is actually a good thing. As we identify cases, we do an even better job of containing the spread through self-quarantine of cases and more stringent self-isolation of close contacts.

Still, even with more testing, we are only identifying a subset of cases. At the moment, only individuals who are symptomatic and have a prescription from their doctor may go to a testing site. Not all cases are symptomatic. Some may have mild symptoms and decide not to get tested. We are only capturing a piece of the pie.

how many cases do we really have?

The correct answer is, we don’t know. And we might not ever know.

One way to know for sure is to screen every person in the country – see Iceland – for active virus. We’d also have to screen for the presence of antibodies to COVID-19, which would suggest that person is a recovered case. With nearly 330 million people, this is not a reality in the US. At least not in the near term.

It is even difficult to use one of the go-to tricks of an epidemiologist. Instead of screening an entire population, you screen a much smaller but representative sample and extrapolate from there. The reason this is difficult is because COVID-19 is impacting communities differently, spreading at different rates, and situations are changing almost by the hour. Every town and city in this country has its own “curve to flatten” and some may be doing a better job than others at slowing the spread. Months from now, we may be able to test for exposure to the virus in random samples across the country to get a better estimate of just how many Americans had it.

The best we can do at the moment is look to the early research coming out of countries like China, South Korea, and Italy, who have been dealing with the pandemic for substantially longer than we have. Some estimate that for every diagnosed case, there may be 7 other undiagnosed cases – the “silent spreaders” so to speak. If that translates to the US, then maybe our community has 56 cases instead of 8. Maybe the US has 350,000 cases instead of 50,000.

We’ve also heard that somewhere between 40-80% of everyone will be infected. The CDC estimates 160 – 240 million cases. What we know about herd immunity is that we need to reach a critical mass of people (typically 60-80% or higher for some viruses) who are either exposed to the virus or vaccinated against the virus for there to be enough resistance in the community to prevent additional spread. If scientists have any say, a vaccine will get here first.

we have to be patient

While the “COVID-19 PANDEMIC” ticker on your television screen might make for captivating news, lets just remember that this isn’t the whole story. Our focus should not be on the raw numbers but on slowing the spread. As we test more, we will find more cases. It might look like we are losing the battle, but rest assured, there is more to the story. Social distancing WILL WORK. And it will work even better in tandem with more testing. We have to trust the process. We have to be patient. And we have to do our best to care for ourselves, our loved ones, and our neighbors, when we all need it most. Remember, the numbers are more than just numbers. They are people.

UPDATE (3/25/20): Promising data out of New York is showing that the rate of daily hospitalization admissions is slowing down. Even though the number of cases in the state continues to rise (which is expected, see above), the key metric is daily admissions rate. Slowing the spread of COVID-19 slows the number of severe cases being hospitalized on a given day and reduces pressure on hospitals. Social distancing is working.

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Our First Case

Yesterday, our city identified its first case of novel coronavirus 2019 (COVID-19). Earlier in the week, the Mayor, with guidance from the city’s COVID-19 Task Force, implemented a series of protective, social distancing measures including the preemptive closing of schools, dine-in restaurants, playgrounds, fitness centers, and other venues that promote large groups of people. The goal of these measures is to slow the spread of the virus and to give our local hospitals the best chance of keeping up with the expected influx of COVID-19 patients.

We are a small US city of approximately 65,000 people, located just outside of a major metropolitan area. Just under 15% of our citizens are above the age of 65 and, thus, at higher risk for symptoms that would require hospitalization. For those under the age of 65, about 12% do not have health insurance and, thus, may be at risk of having overall poorer health relative to those with better access to healthcare. Initial estimates suggest that without protective measures, at its peak, our city could have as many as 17,000 active cases, or about 1 in 4 people. That is what makes these protective measures so critically vital.

In the days, weeks, and months to come, we will experience something that we haven’t experienced in over 100 years with the COVID-19 pandemic. Every minute of every day will be an opportunity to learn, but also an opportunity to react and respond in ways that can ultimately save lives. This blog will track the day-to-day developments in our city and share information that may be useful to help inform other local health officials and response teams as we experience and combat this, together.

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