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COVID-19 Update April 12, 2020: Good News At Last, Testing Again

By Dr. Arthur Lavin

Glossary

  • Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses, and on it goes.
  • Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
  • SARS–CoV-2– the specific name of the new coronavirus
  • COVID-19-the name of the illness that the new coronavirus is causing
  • Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
  • Epidemic– a sudden burst of an illness that comes and goes over a limited time
  • Pandemic– an epidemic that bursts across the world not just one region
  • Spreadability– how contagious is the disease, how many people will end up infected
  • Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
  • Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
  • Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
  • Personal Protective Equipment (PPE)- PPE are any item that covers any part of the body with the design and intent of keeping viruses in the environment from infecting the wearer of the PPE. PPE’s include all masks (which includes respirators), face shields, eye shields, gloves, gowns.
  • Ventilator- a ventilator is a machine that can force a person unable to breathe to inhale and exhale and control both effectively.  They are sometimes called respirators, but during this pandemic the word respirator is now reserved for reference to a tightly fit mask.

Spreadability

This holiday weekend is an excellent time to hear some good news finally!

Across the world, as noted in our last post, the lockdown strategy of Europe and USA continues to perform well, the number of new cases is slowing, even dropping across Europe and many states.  Caution once more- having nations of people isolated in their home only stops the pandemic while you stay at home, the virus still awaits.

Ohio

Very big news in Ohio.

Not very long ago, right here, COVID-19 cases were doubling in number every 2 days, as of Friday, we have slowed dramatically to doubling only every 10 days.

Hospitalization usage is far less than anticipated, in Cincinnati, only 10% of the beds thought to be needed by today have been used.

The Washington Post has noticed and filed a fascinating account of why we are doing so much better than we expected:

https://www.washingtonpost.com/national/health-science/did-ohio-get-it-right-early-intervention-preparation-for-pandemic-may-pay-off/2020/04/09/7570bfea-7a4f-11ea-9bee-c5bf9d2e3288_story.html

The key item I note in this report is that Governor DeWine began to shut down the state, before even one case was identified in Ohio!  This reflects the deep truth noted in an earlier post, the one item that defines success or failure in a rescue is time, do you rescue in time, or too late?  Looks like Ohio acted in time.

Again, this lockdown will only work as long as we stay in our homes.   None of this good news tells us how we can get back to work and play?

This requires crafting approaches that will not spark new surges of illness, hospitalizations, and death, which would only send us back shut up in our homes another 2-3 months- all bad outcomes.  See testing below for more on this point.

South Korea

A word on how to control the spread of COVID-19:  South Korea

As readers of Real Answers will remember, South Korea stands alone as the most successful nation in stopping the spread of the SARS-COVID-2 virus.  It remains to this day, take a look:  https://www.worldometers.info/coronavirus/country/south-korea/

Remarkably, South Korea has outperfomed all other countries and has not had to close all non-essential businesses, relying more on widespread testing than universal isolation like here.

SEVERITY

The good news on severity has to do with US estimates of fatalities.

Again, if you’ve been following us on Real Answers, you know the Imperial College of London is one of the world’s top epidemiology research centers.  They did a detailed examination of the spread and severity of COVID-19 and estimated that should the US do nothing we would face as many as 2.2 million deaths.  Of course, we did not do nothing, and so that nightmare has been averted.

What followed was a White House estimate, whose basis is still uncertain, that if we did everything recommended, that about 100-240,000 Americans would die from COVID-19.

Since then, data from Iceland, the cruise ships, the village of Vo in Italy, all of which have achieved extensive testing, have established that at least about 50% of those infected have no symptoms.   Now, keep in mind, if you want to know the chance that an infection will kill you if you get infected, you must know how many people are infected.  For example, let’s say that in an imaginary nation, we find that about 100,000 people came down with COVID-19 because 100,000 people got sick and came to the hospital.  And that 3,000 of these folks died.  That would make you think 3% of those with COVID-19 will die.   But now, let’s say someone tested everyone in that imaginary nation, and found 200,000 of their people were actually infected, that half were fine, and only half infected got sick.  Now the number who the virus has killed is 3,000 out of 200,000 infected, not 100,000 infected.  So the chance of the virus causing death now drops to 1.5%.

Now that we  know that at least 50% of those infected have no symptoms, the mortality rate for the virus is now cut in half.  And, add in the success of social distancing, and we have two new estimates for how many Americans will lose their life to the SARS-CoV-2 virus:

  • The NIH via Dr. Fauci now estimate, should we continue to follow all recommendations, the loss of life will be 60,000
  • The state of Washington epidemiology center estimates, again assuming we continue to follow all recommendation, the loss of life will be 40,000.

This is excellent, excellent news, but can change for very bad news should we drop what we are doing without a plan.

A caution: The US picture is better in certain spots.  So these lucky places, in Ohio, are now past their peak, but many places in the United States are getting worse, like Detroit, New Orleans, and the spots with rising cases noted later in this post.

TESTING, SUPPLIES, GETTING BACK TO WORK AND PLAY

Testing

We have all heard the cry, for reasons beyond explanation, the cry still needs to be heard.

Especially knowing that at least 50% of people infected with COVID-19 means that unless there is widespread testing, we have no idea who is contagious, we cannot control the pandemic.

Imagine if wildfires were raging across our land, but the fires were invisible without a special test, how could one possibly put out the fire without that test, without seeing the fire?

There are two reasons to do testing, and two types of tests to think about.

Why do testing?

The first reason is currently urgent, to stop the spread.  To this end, we need testing now across the US in all communities, to find out where this fire is raging right now.  Failure to do this testing will lead to new areas of pandemic raging in this or that region, the tragically familiar hot spots idea.

Check out these maps from TOPOS, and go to the one tracking counties in the US with the greatest rise in the number of new COVID-19 cases.  https://covid19.topos.com/

This map demonstrates that with the exception of 4 states (WY, UT, AZ, HA), every state in the US has counties with emerging hot spot counties.

Once the actual spread of the virus becomes visible to us, we can of course, focus attention on stopping the spread in these most vulnerable regions.

This testing requires swabbing to find the virus.

The second reason is to help us get back to work and play.  This goal will take two types of test, the just mentioned swab to find the virus, and a blood test to measure antibody levels.

The swab in the nose tells us who has virus growing in their nose.  The blood test tells us who has already had COVID-19.

If we know who cannot get this illness, who is actually immune, then we can free every single person in this category to go back to school, work, and play.

There are two problems with the antibody test at this time, however:

  1. Many tests being evaluated apparently detect antibodies to any coronavirus, including the 25% of colds we all have had all our lives from very old coronaviruses.  That means such a test could tell someone they have a coronavirus antibody, but it’s an antibody to a cold they had when they were 5 years old, not today’s COVID-19 illness.  Fortunately, some tests are being developed that work to measure only antibody to this SARS-CoV-2, one area in LA is testing its use now.
  2. Even if you are sure your good high antibody levels to SARS-CoV-2 are proven and reliable, we simply do not know if that means you will not COVID-19 again.  We don’t think so, but no one is sure yet  This virus is only 5 months old across all humanity and all history.  It will have to take some time to know if having a mild case protects you from getting it every again.

Getting Back to Play and Work

The American and European model of lockdown has slowed the spread, but will have no impact on the spread of the virus once we leave our homes again.

So how to keep the spread from roaring, how do we actually return to work, school, and play without igniting deadly surge in cases?

Here are some ideas being considered:

  1. The essential goal here that ideally, we would only let people with testing suggesting they are not currently infected, or have antibody showing they had COVID-19 in the past out of the home.  IF this ideal is met, then a second wave surge of deadly infection would be far less likely.
  2. Contact tracing.  This is essential to get out of the home too.  Here it would be the test of a swab finding live virus that would be the first step in finding out everyone who has been within 6 feet of that person.  Think of that bus coming back from the AIPAC convention with one person later found to have active infection, all kids on that bus were immediately quarantined, that is contact tracing. Find out who has been in direct contact and isolate them.   This is not so important if everyone is asked to stay home, it becomes critically essential to do contact tracing so that we can know who has been in contact with active COVID-19.  Without this step, a surge of deadly infection across the nation is far more likely once we leave home.
  3. Protective supplies.  If we want to leave home, we need plenty of good, inexpensive masks, and hand sanitizer, and gloves.

How are we doing as some regions, such as ours, are seeing the lockdown work and need to plan to do these three items to get back together safely.

  • We are doing better with testing, now up to 150,000 tests a day, of the swab for live virus in the nose.
  • We do not have a widely available, reliable blood test to see if you have antibody indicating already recovered from COVID-19
  • We still have very limited capacity for contact tracing.
  • Protective supplies, particularly good masks, are still in very short supply.

And so it appears we are not ready yet to open our doors, but each of these four items can be improved, and as areas such as ours begin to turn strategy to re-opening, we will need to meet each of these 4 needs, or risk starting all over again.

Consider the re-opening of the world’s first COVID-19 hot spot, Wuhan China.  It is officially “open,” but consider what you must do as a citizen of Wuhan to travel:

  1. You can’t buy a train or plane ticket without evidence of two tests (swabs for virus) being negative for SARS-CoV-2.
  2. You get tested at the train station and airport before boarding.
  3. AT your destination you go into 2 weeks quarantine.

We may not do all this, but we will need to test, trace contacts, have protection to open up again.

Again, if the re-open is not done carefully, we should all never forget, the SARS-CoV-2 virus is out there!  Ohio is doubling cases every 10 rather than every 2 days, but we still are doubling.   If we did not screen, trace, and protect well enough, that virus will be more than happy to go to it, and we could see cases exploding, hot spots erupting, deaths piling up, ICU’s overwhelmed, and a new lockdown for 2-3 months to stop this needless second wave.

BOTTOM LINES

  1. Some good news.  The rate of new cases is slowing.  This is happening in the US mainly in very particular spots.  We see a slowing in California, Washington, perhaps in NY, and clearly  so in Ohio.   Cases in all states in the US are still going up, just a bit slower in many states, and sadly, still accelerating in others.
  2. IF we continue lockdown at current rates and better and do not fail the return to work, then estimates of death in the US are now way down, to 40-60,000.
  3. We faced a true crisis when the SARS-CoV-2 exploded into all our lives, and we scrambled to find a path to slow it, and we have.  So now we face a second, just as urgent, challenge, how to leave home, to go back to work, play, and school without reverting to our initial level of emergency.
  4. The good news does not mean the virus is gone or fading, just not spreading as much, once we leave our homes, the virus is sitting there ready to burn again.
  5. This means that a strategy for keeping a relapse from happening is required now.  The three pillars should include:  Testing, Contact Tracing, Protective gear.

If we do these three things, and hopefully including antibody testing, we could return to work, region by region, and even household by household.

The lockdown has helped with our first challenge, but only in the first regions to adopt it and succeed.  Many, many more regions of the US have yet to slow the spread.  Those in regions approaching coming back now face the reality that a strategy to return needs to be in place, or face a tragic recurrence.

We wish everyone a Happy Easter, a Hag Pesach Sameach, and on April 23 Ramadan Kareem, and that all of us come through safe and well,
Dr. Arthur Lavin

 

 

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