Month: March 2020

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
Updates

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.

Latest Posts
Categories
Reactions

2.2 Million Math

The White House just shared its worst-case-scenario estimates for the possible number of total deaths in the US due to COVID-19. 1.6-2.2 million Americans could be at risk of dying. Here is my quick take on where that number comes from.

We have approximately 330 million people living in the US today.

The CDC estimates that 50% – 70% of Americans could be infected with coronavirus. That translates to about 160 – 240 million cases.

The VERY limited evidence to date on case fatality rate suggests that anywhere between 0.25% – 3% of COVID-19 cases result in death. The current US case fatality rate, based on early numbers, is around 1.5%. The true US case fatality rate remains to be seen, but it is likely that these early numbers are over-inflated. With this in mind, we could conceivably land somewhere around 1% of COVID-19 cases being fatal. (This still makes it 10 times more fatal than seasonal flu).

Thus, 1% of 160 – 240 million cases is 1.6 – 2.4 million deaths in the US. This is my best guess at how the White House came up with its numbers. As you can see, it is a very inexact science. And perhaps premature to be making these kinds of projections. Still, we cant ignore the implications.

The President and his advisers described this as the worst case, if we were to do nothing at all to slow the spread of the virus. Fortunately, we are doing something and it seems most everyone is in agreement that social distancing is critical. The White House announced that it is keeping the nation’s mitigation efforts in place through April 30th.

It was suggested that with these measures, the US death toll could be held to between 100,000 and 200,000. For that to occur, based on the numbers above, either far fewer people would need to become infected or the virus would need to be far less lethal than current estimates. Approximately 1/10th as lethal.

Perhaps the virus is “only” as deadly as seasonal flu, with the main challenge being the sheer number of patients needing acute, intensive care all at once. In this case, fatalities may be more a function of healthcare system capacity than of the virus itself. We really don’t know, and may not know because the two are inextricably intertwined at the moment.

Regardless, these are all hypotheticals without a ton of supporting evidence. 100,000 to 2.2 million is an immense range with an immense amount of unknown left in between.

UPDATE (3/30/20): A study from the Imperial College COVID-19 Response Team, whose members include the World Health Organization and UK Medical Research Council, projected that in the absence of any mitigation efforts, 2.2 million American could die from COVID-19. This worst-case-scenario assumes that 0.9% of cases overall result in death and that close to 80% of Americans become infected. These numbers are similar to those I outlined above.

The study also demonstrates that the number of deaths are reduced significantly as the number, duration, and intensity of social distancing measures increases.

CNN posted this graphic earlier today which provides a visual of the White House statements (apologies for the screenshot quality).

Latest Posts
Categories
Perspectives Resources

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.

Latest Posts
Categories
Perspectives

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.

Latest Posts
Categories
Research

Hindsight is 1918

We can learn from the past. And 102 years is a long time to prepare for the next pandemic. So what did we learn in hindsight from the 1918 Pandemic Flu, and is it too late to keep history from repeating itself in 2020?

I wonder if she is posting to her H1N1-18 Journal

A New York City typist wears a flu mask while at her desk, October 16, 1918 National Archives and Records Administration
Influenza Encyclopedia, University of Michigan Library

I’ll admit it. When our schools closed before there were any known cases in the community and before any neighboring cities closed theirs, I questioned whether there was any science that justified my kids being home (and invading my office). Well, I dug up some evidence and it turns out that preemptive school closings during the 1918 flu pandemic was a key social distancing ingredient that saved tens of thousands of lives, if not more.

In St. Louis, schools closed within about 2 weeks of the first flu case to be identified, and about two weeks before the virus began to peak in the community. In Pittsburgh, schools closed about 6 weeks after its first case and almost 2 weeks after the flu began its peak in the city. What we saw was a sizable difference in the number of deaths in St. Louis compared to Pittsburgh, where the rate was 2.25 times higher.

Weekly Excess Death Rates From September 8, 1918, Through February 22, 1919; adapted from Nonpharmaceutical Interventions Implemented by US Cities During the 1918-1919 Influenza Pandemic

Seems like Pennsylvania as a state was slow to react to the pandemic. Philadelphia, much like Pittsburgh, waited weeks after the first known cases before it implemented any social distancing measures. St. Louis, as we know, took much quicker action. The result, a dramatic “flattening of the curve” in St. Louis and, again, the cumulative death rate was cut in half.

1918 influenza related death rate in Philadelphia and St. Louis; from Public health interventions and epidemic intensity during the 1918 influenza pandemic

Looks familiar, right? So we did learn something from the 1918 flu pandemic. The question now is whether we’ve acted on it soon enough.

As Long as it Takes

Now something you wont want to hear. We actually want the spread of COVID-19 to last as long as possible. It sounds counter-intuitive, but it is true. We need to stretch it out as long as possible if we want to save as many lives as possible.

Take a look at St. Louis versus Philadelphia again. Before, we were so interested in the death rate (the y-axis) that we forgot to look at the timeline (the x-axis). The Philadelphia outbreak was all said and done by early November, whereas the St. Louis outbreak lasted 2 more months, until the end of the year. However, for every 1 person that died in St. Louis over the course of the pandemic, more than twice that number died in Philadelphia. The city had more than 12,000 deaths in total.

The US as a whole lost 675,000 lives to the 1918 pandemic.

Lets hope we learned our lesson and that the measures we are taking to slow the spread of COVID-19 started soon enough and last long enough. Then again, we always could have started sooner. Hindsight is 20/20…

Want to learn more about the 1918 flu pandemic in America? Visit the Influenza Encyclopedia by the University of Michigan.

influenza encyclopedia
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
Perspectives

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.

LATEST POSTS
Categories
Research

Early Data

The Centers for Disease Control (CDC) just released some of the early data on severe outcomes, including hospitalizations and fatalities, for the first 4,226 COVID-19 patients in the US. Health officials have been relying primarily on data from other countries like China and Italy, whose populations and healthcare systems are not necessarily comparable to our own. Though this continues to be an evolving situation, this early research is telling. It supports something we know, and raises a red flag on something that needs more attention.

Case fatality rates

Forty-four COVID-19 cases with known status had died as of March 16, 2020. That represents approximately 1% (1 in 100) of identified cases. (I will address whether this is a true representation of case fatality rate later on). Cases 85 years-old and above had the highest fatality rates, ranging from 10% of all cases in that age group, up to 27% of those hospitalized (Table). Among cases 65-85, 3-11% had died. The case fatality rate among those ages 20-54 was less than 1%. This is in line with what we have learned and heard previously about COVID-19 – that older individuals are heightened risk of dying. What we learned next was somewhat more surprising.

Case Hospitalization rates

Among the 12% of cases (508) with a known hospitalization, we again saw that the highest number of patients, 35%, were cases over the age of 65. However, we also saw that younger patients, between the ages of 20 and 54, made up 38% of all hospitalizations. This suggests that although the risk of death is lower for younger individuals, they are still at risk of severe disease that requires hospitalization. This is important because it addresses a dangerous misconception that young, healthy people are not at risk of serious illness from COVID-19, which has been a detriment to social distancing measures enacted to slow the spread of the virus.

what does this all mean?

This are very early data based on what will amount to be a very small number of the cases we see in this country. The analysis was limited to the 2,449 cases whose age was known. Further, these data are still incomplete. Most cases are still unresolved. Some may still be hospitalized or yet-to-be hospitalized. Some may die. Most will recover. The report also did not include information about underlying health conditions, which we know also increase the risk of death.

When it comes to case fatality rate, we are not yet seeing the full picture. These initial cases came before widespread testing was made available in the US. In other words, these cases likely came to our attention due to illness or because they were exposure to an already confirmed case. Some evidence suggests that for for every confirmed case, there are 7 more that have yet-to-be identified.

The number of identified cases will continue to rise in the US, and with that increase in cases, the true case fatality rate will surface. If China is any indication, we can anticipate it to be closer to 0.1% (1 in 1000) or less.

Table: COVID-19 severe outcomes by age – United States, february 12-march 16, 2020
Age group (cases)Hospitalization ICU admission Fatality
0–19 (123) 1.6–2.5 0 0
20–44 (705) 14.3–20.8 2.0–4.2 0.1–0.2
45–54 (429) 21.2–28.3 5.4–10.4 0.5–0.8
55–64 (429) 20.5–30.1 4.7–11.2 1.4–2.6
65–74 (409) 28.6–43.5 8.1–18.8 2.7–4.9
75–84 (210) 30.5–58.7 10.5–31.0 4.3–10.5
≥85 (144) 31.3–70.3 6.3–29.0 10.4–27.3
Total (2,449) 20.7–31.4 4.9–11.5 1.8–3.4

Lower bound of range = percentage among total in age group; Upper bound of range = percentage among total in age group with known hospitalization status, ICU admission status, or death; Table adapted from CDC.

LATEST POSTS