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.
• Live Virus Swab– this is the swab which attempts to swipe live virus from one’s nose or throat tosee if you are currently infected.
• Antibody Test- (aka serology test) this is the blood test which looks for antibody to the SARS-CoV-2 virus to see if you have been infected in the past.

Spreadability

THE RE-OPEN

Many states in the country, including Ohio, have instituted formal steps to re-open their communities to a range of work and play activities that will allow everyone to leave their homes and once again gather with others.

This began May 1 in many areas of the nation.  So, are there any signs if it is going OK or not?  The answer as of today is that the process is just in its first days, too early to say for sure, but there are two main indicators of how it might go.

Range of strategies

First, let’s look this a range of three strategies:

• Open up wide.  Some states have chosen to say, let everyone do what they like.  Hair salons and tattoo parlors and gyms opened to all in Georgia on April 24, not all businesses were asked to re-open, but enough, and enough high contact businesses to give the state the impression of letting it all open up wide.
• Open up in stages.  Most states contemplating allowing people to gather in small steps, to see if cases surge at each step, so if a re-open step backfires, it can be reversed without reversing too much.  This is the strategy seen in states such as our own Ohio, and NY and California.
• Make sure real contact tracing can happen.  Paul Farmer is one of our era’s public health giants, working to stop the ravages of AIDS in Haiti and other epidemics across the world, to great success. His program, Partners in Health, based in Boston, decided to help the US out this time, and the states of MA and our own OH have engaged PIH to train a good number of contact tracers, to see where COVID-19 is surging, for real.

Two Early Signs of How Re-Opening is Going

• IHME and CDC/FEMA projections.
  • The IHME is the Institute for Health Metrics and Evaluation at the University of Washington, one of the most highly regarded epidemiology centers in the world.  They have been issuing forecasts for the total number of people expected to lose their life to COVID-19.  For some time, they have predicted a loss of 72,000 lives, by August 4, 2020.   This organization has access to anonymous data on national movements of people using cell phone tracking information and so they can actually see how much we gather.  The move to reopen has already led to more gathering, and this as well as explicit plans to re-open led the IHME to overhaul their projections, which have now gone from 72,000, to 134,000 lives lost.  They also observe that if social distancing had been preserved, the additional predicted 62,000 lives lost would not likely be lost.  Curiously, the IHME had been a highly favored source of projections in the US government, until they revised their forecast this week.  The day they revised, the CDC dropped them from their webpage.
  • CDC/FEMA.  Our CDC and FEMA teamed up to estimate, given current plans to re-open, and trends in how the virus is spreading, the number of Americans who will die every day during the pandemic.  The country is at about 1750 deaths a day now.   The new CDC/FEMA workingestimates suggest current trends will put as at 3,000 deaths a day from COVID-19 by sometime in June.
• COVID-19 cases are on the rise across the US, prior to this re-opening.  Now we shift from forecasts to actual experience.  Just looking at the number of Americans who get infected with COVID-19 every day, across the whole nation, the trend is fairly steady- about 25-30,000 new cases a day since April 3.  But a large chunk of COVID-19 in the US is in the state of NY.  Looking just the state of NY, the number of new cases per day is plummeting over the last week or so, now down to about 5,000 across the state.   So, take NY out, and when you look at the rest of the US, the number of people known to be infected is actually rising, and this before any of the re-opening, going from about 18,000 cases a day a week or so ago, to now over 20,000 new cases a day.

As has been stated in Real Answers in many prior posts, the impact we have had with our lock-down, is only limited to the lock-down.  That is, we slowed the rate of infection, but did not clear the nation of virus.   This means that when we get back together to work or play, there will be more infections, the virus, which is still all around us, will spread again more rapidly.   This central reality informs the new projections from the IMHE and CDC/FEMA and real trend lines in new cases across the US outside of NY.

The only way to avoid major bursts of overwhelming hot spot infection is to know where the outbursts begin, and control them.

As said before, that requires identifying those infected, their contacts, and isolation of all who are contagious.  And only opening the doors once the numbers of new cases have been reduced to the point we can detect new outbursts when they start.

The problem is that our nation is not at a point when new cases are small enough, just the opposite, they are still burgeoning.  And we simply are not able yet to detect small outbursts when they start, trace their contacts, and isolate all contagious.

Lastly, we are witnessing, very, very large outbursts of COVID-19 in nursing homes, meat packing plants, and prisons, in essentially very such place where we test to see.  And in every community where this is happening the number of COVID-19 infections grows in the surrounding towns and cities of these facilities.

CHILDREN ARE CONTAGIOUS

Two new studies find children are contagious for the SARS-CoV-2 virus, the cause of COVID-19.

One is from China where they found that children are about 1/3 as likely as adults to get COVID-19 after exposure.  But if infected and in school, the sharp increase in contacts leads to the virus transmitting at rates seen in adults.  They predict closing schools drops the spread of COVID-19 by about 50%.

And in Germany they found that children with COVID-19 are packed with just as much virus as adults.

Treatment

A New Drug Fails

In the May 7, 2020 issue of The New England Journal of Medicine,  a well-designed study looked at how well a drug now used to treat AIDS, lopinavir helped treat people with severe COVID-19, when combined with ritonivir which is thought to help anti-virals work better  (notice both drugs end with –vir the clue that it is in the category of an anti-viral).

The study found that this drug combination did not work well to reduce the harms done to people with severe COVID-19.

BOTTOM LINES

1. The SARS-CoV-2 virus is all over the world, and all across the United States.  It is spreading more and more outside of New York.  There are many, many growing spots of infection in many towns across the American heartland.   Many communities have quite large outbreaks in facilities in their community, that then spill over to the community.
2. Given that the virus remains quite widespread, we have enjoyed a lull in the crush of infection only because we have stayed home and apart.   There are strong indicators that should we return to work and play, the virus will surge.
3. The only way to keep surges from exploding from small outbreaks to huge flares with swamped towns, is to catch the signal that a small outbreak is happening, and stop the virus from spreading wildly.  This can only be done by identifying those small outbreaks, tracing their contacts, and isolating all contagious.
4. Detecting and isolating small outbreaks is hard to do when their is a lot of viral transmission happening before a re-open.  It’s like trying to hear a radio signal when the static is very, very heavy.
5. These steps can be done.  Many nations have succeeded brilliantly in doing so.  Take the example of Taiwan, where over 23 million people live in dense proximity, and closer to Wuhan than we are to Boston.  This nation as of May 5, has suffered only 6 deaths. If we had done what Taiwan did to control the spread of the SARS-CoV-2 virus, we would today have a total of 85 deaths instead of 72,725.
6. Early indications are that children sadly are contagious.  They remain extremely less likely to suffer serious symptoms, with the rare exception of a vasculitis (see earlier post), but can transmit the disease, so opening schools will likely increase the spread of the virus, potentially dramatically.
7. A recent report on a promising new drug to treat COVID-19 simply did not work.  A grim reminder that most promising new ideas in medicine do not translate into actual working solutions.   Our hope for a drug or vaccine that works lies in the enormous number of attempts being made.  Even should most fail, the hope remains that at least one will work well enough to get us all out of this danger.

COVID-19 is a disease capable of tragic outcomes.  It has not been truly tamed in the United States yet.  It could be, if we chose to, and that is proven by the success of Taiwan, and many other nations.  We now lose nearly 2,000 American lives a day to this infection, the nation of Taiwan has lost a total of 6 from last November to today.  It remains unclear why we have not taken steps to stop the loss of life as so many other nations have.

As we embark on going back to work and play, there are clear indications that we do so in the setting of rising numbers of infections across the nation, outside of NY, and an inability to really detect and stop small outbreaks before they pop into large hot spots.

Highly reliable forecasters are therefore changing their forecasts, and current decisions appear to be moving us towards over 130,000 deaths by August 4, and more beyond that date.

Our hope is fairly straightforward.  It is that our nation make decisions at the national level, to reduce, not increase, the number of people this infection will kill.   It turns out in every pandemic humanity has experienced, this path is the surest path to restore the economy, too.

We hope that these trends fail to materialize, that somehow the SARS-CoV-2 virus will stop spreading now.  That would be wonderful, but if it doesn’t change what it does, it is concerning what our nation is doing now.  There are other choices that can be made, we should adopt the steps that other nations know truly work.

To your health,
Dr. Arthur Lavin