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COVID-19 Update, March 12, 2020: Cases are spreading in the US, no good sense of our numbers or trends yet

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
  • SARS-CoV-2- the specific name of the new coronavirus
  • COVID-2019- 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

 

 

 

 

Spreadability

The update on the COVID-19 illness in our nation is still filled with uncertainty.

As of March 10, Johns Hopkins, which has been doing an outstanding job of tracking the epidemic posted this graph of the trend of known cases Covid-19 in the United States:

Let’s take a look at this important graph

  • It goes from January 22 to March 10.
  • Each blue dot shows how many cases the Johns Hopkins group stated were surely diagnosed in the US, so on March 10 they said we had 800 cases.  This is likely an underestimate as some sources said we hit 1,000 by the 10th.
  • The Trend- A key finding on this graph is that we are seeing a classic exponential curve
  • The Doubling Time- A second key finding on this graph is that it gives us the doubling time

 

 

 

Exponential Curves

An exponential curve traces how frequent something happens if the number of the event goes up by an exponent.  The simplest exponent to ponder is the number 2.  If 2 is our exponent then the event will happen once, then 2 times, then 4 times, then 8 times, then 16 times, doubling every step of the way.   This example showed 5 doublings, and that gets us to 32 events.  But keep going, say doubling the number 10 times, you end up with 1,024 times.  Just go to 20 times and you get to over a million times.

All exponential curves look the same, they start off sort of flat, after all going from 1, to 2, to 4, to 8 events is not so many events.  But keep going and the pace quickens.  In our graph, it seems that around March 3rd or 4th, the doubling of cases in the US started generating larger numbers, and much faster.  By just a few days ago, March 6-7, the curve started really taking off, becoming far more vertical.

And, this is not a surprise.  All epidemics typically go exponential until something stops the rise- either the infection has infected all it could, or its season is up, or people do something to stop it.

Doubling Time

How fast an exponential curve climb depends on the doubling time and how many doubles occur.  So far, in the United States, there is no limit apparent on the number of doubling of the number of cases in sight yet, at least according to this graph.  Should that happy day come, the line would stop getting steeper.

But as long as the line remains exponential, the doubling time tells us how fast the numbers double, right now in the United States that number is has held stead at about 3-4 days throughout March, so far.

The Big Problem with the Numbers

The big problem with the numbers is that they are likely a very severe underestimate.  But more to the point, we simply do not know if they are about right or way underestimating for one very simple fact.  The United States is increasingly standing alone in not testing everyone who might be infected, for a sad but simple reason- we have failed to distribute tests to do so.

As of March 10, since January 18, it appears that the CDC and Public Health Labs in the United States has conducted a total of 11,079 tests for SARS-CoV-2, the virus of COVID-19.

That number is going up, but is a very, very far cry from the millions of tests that need to be done to really know how many of us have the infection, where the cases are, and how our measures are working, or not.  To put this into some perspective, we have done about as many tests since January, as South Korea (a much smaller country) does every day!

The government promises that a million tests will be done soon, we should be prepared to find out that when we test a million instead of a total of 10,000 cases we will find many, many more cases of COVID-19, the US numbers will seem to have climbed very suddenly.  There won’t actually be anymore cases in that moment, we will just now be able to see them, and it will likely cause a panic given the sudden nature of the jump in numbers known.

Can we blunt the exponential curve?

This is the question.  If we cannot, it will really start to spread very, very rapidly now.

China offers us hope,here is a graph of how cases have accumulated in China, but only through March 1:

Notice how somewhere around the middle of February, China’s exponential curve stopped being exponential, it went flat instead of zooming.  From January 20 to mid February, the number of total cases of COVID-19 in China went from nearly zero to about 75,000, in just a few days, then suddenly, since then it has failed to go from 75,000 to much over 80,000 cases.  Even today, March 11, 10 days after this graph, the total number of cases in China is still at 80,790, they have only seen 12 new cases in the last day.

Notice the blue line is all other countries, which had back on March 1 still been doubling at low numbers, remember the US exponential curve took off towards vertical after March 4.

Readers of these updates will recall how this likely happened:

  1. Identify all cases.  This requires screening everyone for symptoms, in this case fever, and sending everyone with fever to a special COVID-19 center where it can be found if they are infected without spreading it.
  2. Isolate all cases.  In China, you don’t go home if you are diagnosed.  If well you go to an isolation center until no longer contagious, if very ill you go to a COVID-19 hospital until well and no longer contagious.

This approach might explain the dramatic drop in new cases in China, the interruption of further exponential increases.

We are not doing this in our nation, here in America.  Because we only have used 11,000 or so kits, we have no idea about who all those infected are.  Further, if diagnosed, and not too sick, you are quarantined at home, the very place where spread to new cases is most likely for COVID-19.

But we will see, will our United States curve continue to go up exponentially, or will our approach stop this rise, we will see soon because our approach is in place, and if it works the number of new cases should drop dramatically.  If our approach does not work the exponential nature of the rise will continue.  Keep in mind our current number of about 1,282 cases is very likely, but not certain, to rise substantially once we test millions rather than a few thousand, people.

The Cuyahoga County Cases- A friend of a friend is not a risk

Yesterday, the first 3 cases of COVID-19 were proven to be here in our County.  Keep in mind, those are the first 3 people tested positive, again there may be many, many more cases we don’t know about because we haven’t tested that many people, yet.

We have heard from many families that someone they know was in the same room as someone who was in the same place as one of these 3 infected people.

So let’s talk about who is at risk in this scenario.

Clearly the person known to be infected can get sick and can spread the illness, we will call him the case.

Now, anyone who has been as close as 6 feet or closer to the case can get infected.  They are at risk for getting infected, and should be isolated in case the do turn out to be infected, to prevent further spread.  We call all such people in this situation a direct contact.  

But how about all the friends, family members, classmates of a direct contact.  We will call all indirect contacts.  At this time, per the CDC, indirect contacts are not at high risk for getting infected and can go about their usual lives with no restrictions.

How is the virus of COVID-19 spread?

Hard to believe, but this virus, SARS-CoV-2 is still very new, it only started infected humans in late November.  So we don’t know for sure how it spreads, but here are some thoughts:

  • Most scientists believe it is spread in the air.  A sneeze or cough propels millions of the virus into the air.  Typically they are thought to go about 3 feet and inside that distance can land on my eyes, nose, or throat.  If that happens I can catch the illness.  The six foot safe distance is extra precaution.
  • Today it was reported that live SARS-CoV-2 viruses were recovered off steel and glass as long as 3 days after landing there.  We do not know if this means people can get infected touching steel 3 days after someone coughed on it, but it makes that a possibility.

 

Severity

The COVID-19 illness tends to leave children alone.

As of yesterday, no child under 10 years of age has died of COVID-19.

Mortality rates for 10-30 year old people remain very low.

Mortality climbs steeply after age 50-60.  People in their 60’s have a 6% chance of dying if infected, and if over 80 that climbs to 14%.

Mortality for older adults climbs if they have heart disease, chronic lung disease, cancer, or diabetes.  Not clear if danger rises for children with such illnesses.

At Advanced Pediatrics

We are in close conversation with public health leaders, and will be announcing plans to reduce risk to all children, their families, and our staff this week.

We can share the news that UH has established safe areas for COVID-19 testing, but given the severe shortage of testing kits can only test people who have had contact with someone outside the country in a high risk area.

We will be reducing items in the waiting room and exam room to reduce the number of objects that could hold the virus, so if you want to have a toy during your visit, bring one along.

We have always been attentive to not having people wait, so you have likely noticed our waiting room isn’t really a waiting room, we do not ask people to expect to wait.  We will continue to expedite movement from the front desk to exam room and then out, to keep our office from being a place where people sit together in the waiting room.

Coming this week will be guidance on how best to use our help during this epidemic.  Remember that our office can do video visits?  You may recall that at this time only Medical Mutual has agreed to cover such a service, but we are in conversation with all major carriers to see that given the epidemic’s urgency if they will begin to cover this service.

It is a good time now, for families in our practice, to learn how to make a video appointment, call our office for guidance.

BOTTOM LINES

  1. The United States is in an exponential rise in cases, and the numbers are getting steep in their increase.
  2.  The current plan in the US of social distancing and limited testing and very limited isolation may or may not blunt the rapid rise in numbers infected in the US.   A much more robust approach in China might have succeeded in stopping the spread to a major degree.  We will see if our measures in the US will.
  3. It seems to spread by air.  May or may not spread on surfaces.
  4. Kids remain protected from harm, no child less than 10 years old has died to date.  In fact, only 2.1% of people diagnosed with COVID-19 in China were children.
  5. Stay tuned if you are in our practice, try to learn how to activate a video appointment, it is very easy.
  6. Cleveland medical centers are gearing up for testing, but access to them remains very limited, at UH you have to have contact with someone from an international high risk area to qualify for testing.

We will remain vigilant in pursuing approaches to help, and keeping the information going.

To your health,
Dr. Arthur Lavin

 

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