Categories
Communities Perspectives Planning

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.


LAtest Posts
Categories
Planning Projections

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.


Latest Posts

Categories
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.


Latest Posts
Categories
Planning Resources

Community Considerations

With more test results coming in, our city is now up to 27 known cases. Our task force continues to respond to the immediate needs of the community, and prepare for those to come. The following provides a general idea of the types of questions we are asking to help inform the city’s COVID-19 response strategy, and why they are important.

COVID-19 Response Plan Considerations

Health System Preparedness

The ability of the health system to handle the surge of COVID-19 patients is paramount. It is the primary reason for our social distancing efforts to mitigate the spread of the virus. How do we gauge the capacity of our city’s healthcare system?

  • How many hospital beds does the city have?
  • How many ICU beds?
  • How many ventilators?
  • How many healthcare staff?
  • What is the existing supply of personal protective equipment?
  • How is the city procuring more of all of the above?
  • What is the plan should hospitals exceed capacity? (Are there temporary treatment facilities)?
Testing Procedures

As the virus (and awareness of the virus) spreads, the demand for testing will increase. Having an appropriate protocol in place will help ensure organized and efficient testing procedures while, importantly, adhering to the necessary safety and social distancing guidelines. What are some of the key testing considerations? (These apply to non-hospitalized suspected cases).

  • Testing locations – ideally situated away from hospitals to avoid congestion and unnecessary exposure
  • Drive-up/mobile testing when possible
  • With a physician’s prescription only – physician will determine if symptoms and medical history meet COVID-19 testing criteria
  • By appointment only
  • Priority testing and/or separate testing site(s) for healthcare workers and first responders
Persons Under Investigation

Persons under investigation (PUIs) include individuals with symptoms whose test results are pending, and asymptomatic individuals who may have been exposed to a lab-confirmed COVID-19 case. How do we manage and instruct PUIs to prevent the further spread of virus?

The CDC has developed health department guidelines for (1) how to evaluate PUIs, (2) how to report PUIs and confirmed cases, and (3) what preventative measures a PUI should take based on their risk of exposure.

Confirmed Cases

What is the course of action once a persons’s test comes back positive for COVID-19? If he/she does not require hospitalization, the CDC has developed guidelines for self isolation and home care. This includes guidance on when it is safe for an individual to discontinue home isolation.

First Responders and Emergency Medical Services

How do we ensure the safety and preparedness of our first responders? Police, Fire, and EMS departments will play a crucial role during the COVID-19 crisis. The CDC has developed EMS guidelines for patient assessment and transport, the use of personal protective equipment, the cleaning of vehicles, and other important steps in responding to an emergency.

High Risk Groups

This includes seniors (primarily those in senior housing), individuals with disabilities, low-income households, and the homeless. What procedures are in place to ensure the health and safety of these individuals, including access to healthcare services, food, essential services, and housing/shelter? What state and federal aid programs are available to further support these individuals?

Continued Social Distancing Measures

How do we maximize our efforts to slow the spread of COVID-19 in the community?

  • “Stay-at-home order” for all non-essential employees
  • Non-essential travel restrictions
  • Non-essential retail businesses closed
  • School closures
  • House of worship closures
  • Public library and offices closed
  • Cancellation of all public events and gatherings
  • Restaurants open for take-out only
  • Essential businesses (eg, pharmacies, grocery stores) recommended to limit the number of customers to maintain social distancing guidelines (ie, 6 feet between individuals)
Communication

How is this information being conveyed to residents and businesses clearly, concisely, in a timely fashion, and with the utmost consideration for the angst and uncertainty that many individuals may be experiencing at this moment in time?


LAtest Posts
Categories
Planning Updates

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.


LATEST POSTS
Categories
Planning Projections

The Case for Social Distancing

As hospitals scramble to prepare, they are asking the question, just how bad could it get? As I was trying to find answers to help inform our local hospitals, I struck gold with the COVID-19 Hospital Impact Model for Epidemics (CHIME), an online tool developed by the Predictive Healthcare team at UPenn Medicine.

The tool helps project the expected number of daily hospital admissions, intensive care unit (ICU) admissions, and admitted patients in need of a ventilator, as well as admitted patient totals, based on a number of assumptions about the community, hospital system, and spread of the virus. It is not predictive, but rather a tool that could be helpful in planning for the anticipated demand on the local hospital system.

I ran an analysis for Small City, USA. My model assumptions were as follows:

Model Assumptions

1 known case
1 known hospitalization
6 day case doubling time
5% case hospitalization rate
2% case ICU rate
1% case ventilated rate
7 day hospital length of stay (LOS)
9 day ICU LOS
10 day ventilator LOS
50% hospital market share (we have two main hospitals)
65,000 population


The key consideration here is case doubling time. A 6-day case doubling time simulates the spread of COVID-19 unchecked, without any mitigation efforts like social distancing. In other words, we are modeling the worst case scenario, given what we know and where we are today. Here are the results.

Figure 1: Projected number of daily COVID-19 admissions

Without mitigation, COVID-19 hospital admissions peak at 56 days (8 weeks) with 18 new admissions per day, including 6 ICU patients, and 3 on ventilators (Figure 1). Because average length of stay is 7 days for each admitted patient and longer for those needing intensive care, the projected total number of admissions on day 56 paints a dire picture.

Figure 2: Projected total COVID-19 patients, accounting for arrivals and discharges

At its peak, COVID-19 patients would account for 122 hospital beds in 8-weeks time, with 62 patients in the intensive care unit, and 34 on ventilators. It is unclear whether our hospitals currently have, or will have, the beds, ventilators, supplies, and personnel needed to treat this number of patients (Figure 2). And what does the rest of Small City look like?

Figure 3: The number of infected and recovered individuals in the hospital catchment region at any given moment

At around 9 weeks, without social distancing measures, we would see more than 17,000 cases at the peak of the COVID-19 outbreak. That is nearly 1 in 4 Small City residents (Figure 3).

Social Distancing is the Difference Maker

Now back to that oh-so important case doubling time. If we can add just 2 days to the amount of time it takes for the number of cases to double, from 6 to 8 days, best achieved though social distancing measures, we can push the peak out by 2 weeks and reduce the number of daily hospital admissions by more than 40% (Figure 4).

And the more social distancing the better. If we can reduce social contact by 25%, we see a 65% drop in daily admissions (Figure 5), and the total number of community cases drops from 17,000 to just over 10,000 at peak (Figure 6).

There is a reason why schools are closed, businesses are closed, and we are being asked told to isolate at home. Social distancing works. Without it, we risk overloading our hospitals and putting COVID-19 patients – and healthcare workers – in a very dangerous place.

For more on how social distancing works to slow the spread of COVID-19, check out this Washington Post animation.

Figure 4: Projected number of daily COVID-19 admissions, with CDT of 8 days
Figure 5: Projected number of daily COVID-19 admissions, at 25% social distancing
Figure 6: The number of infected and recovered individuals in the hospital catchment region at any given moment, at 25% social distancing

LATEST POSTS