Updated July 21, 2020
I’m reading The Splendid and the Vile, Erik Larson’s latest work of non-fiction focused on Winston Churchill’s first days as prime minister. Churchill enters office as Adolf Hitler invades Holland and Belgium, Poland and Czechoslovakia having already fallen, and the Dunkirk evacuation just two weeks away. For the next twelve months, Hitler would wage a relentless bombing campaign on UK cities, killing 45,000 Britons, while U-boats paralyzed commerce and the supply chain and a land invasion seemed imminent. A different time, a different war, a different villain wreaking indiscriminate pain, suffering, and death on millions.
Depending on the definition of patient zero, we are now 6, 7, 8, or 9 months into the COVID-19 pandemic and the war waged against the novel coronavirus SARS CoV2. I’m finding it increasingly difficult to compose these updates as I feel I’ve already presented what needs to be said. In a post one month ago I predicted the current surge, its geography, age group, and lower mortality. This was not the result of extensive research, clairvoyance, insider knowledge, or a lucky guess. All that was required to make those predictions was a reasonable facility with basic math and a general understanding of the science of infectious disease.
Our colleague, Michael Smith, has spent his evenings and weekends developing models to predict the course of the pandemic with remarkable accuracy. If current trends continue his model predicts we may achieve the rudiments of herd immunity by the end of August. My last 5 years conducting real-world evidence research has taught me both the value and the limitations of healthcare modeling. Models are limited to the assumptions upon which they are built and can’t account for information that is in error or the vicissitudes of human nature and their influence on those responsible for public policy. At 15,000 new cases per day in just one state, Florida, restrictions get reimposed; when deaths double, or triple, lockdowns get re-instituted; irrespective of public policy, fear will reverse re-engagement for many. If parents won’t send their children to school and those over 60 self-quarantine the economy stalls, the possibility of herd immunity fades and the pain, suffering, and death of so many will be in vain.
I hope and pray that, if the assumptions are correct and public policy doesn’t change, Michael’s model is accurate and we exhale a sigh of relief come September. But as the wise men say “hope is not a strategy” and “triumphs of hope over reason” make good fiction. All of which brings me back to Larson’s book on Churchill in 1941 London during the blitz. His indomitable spirit is a lesson to all of us as we persevere in these most unique and difficult times.
Because the news of the past few days warrants the salve of humor I offer the word of the week — Coronacoaster (noun): the ups and downs of a pandemic. One day you’re loving your bubble, doing workouts, baking banana bread and going for long walks and the next you’re crying, drinking gin for breakfast and missing people you don’t even like.
Updated April 10, 2020
My father had a small retail clothing business in Philadelphia. Twice a year he would drive north to the garment district in NYC for the next season’s apparel buy. These trips morphed into family weekend getaways. Driving north we’d cross the Delaware line into New Jersey near Trenton over a bridge that was emblazoned in 20 ft high letters spelling out “WHAT TRENTON MAKES THE WORLD TAKES.” Yes, it was a global economy in 1966. If America is to be open for business, the world needs to be open for business.
The headlines may make this proposition seem unattainable yet I am optimistic. Immersed as we are in this first phase of the pandemic in which we pray daily for new case activity to peak as daily death counts rise we need to be ever cognizant that the present is the past and our focus must be on the future. The future is the next phase (2) of the pandemic in which recoveries exceed new cases, immunity allows for social re-engagement, tracing allows isolation of newly infected who receive appropriately timed treatments that lessen disease severity.
In the next four weeks the US and the rest of the industrialized world should: see social distancing flatten the curve; have readouts on a half dozen clinical trials evaluating the effectiveness of treatments (chloroquine, hydrochloroquine, remdesiver, convalescent plasma); likely have three approved accurate serologic tests (antibody assays) that can determine immunity and have the data to more effectively characterize high-risk populations. With this data and these tools Phase 2 is conceivable. We can begin to explore scenarios in which those who are immune can fully re-engage without risk to themselves or others. We can define the high-risk individuals who must continue to isolate pending a vaccine or treatment that conveys the equivalent protection from the risk of severe illness. Immunity passports can be issued to those who have antibodies while those at low risk can re-engage as long as they undergo frequent testing for viral RNA and if positive isolate and trace contacts.
Trenton may no longer be a hub of manufacturing but the global economy it recognized a century ago is in full effect today. For America to be open for business the world must also be open. International agreement on how to re-open with the least risk of a second surge will require acceptance of measures that impinge on our personal freedoms. We were successful in doing this after 9/11 and I am optimistic we can be successful again.
Updated April 2, 2020
It may seem that the Pandemic has been with us since December, but most of us have only just completed the second week of sheltering at home. My last business trip concluded just three weeks ago on March 8. Social media abounds with commiseration for the shared experience of running out of Netflix shows to watch, but for some like me, that happened months before COVID-19. We want to believe that this will be over soon, but such thinking begs a triumph of hope over reason. Our shared reality is that the pandemic in the US has just begun and we need to be prepared for months of sheltering but not necessarily social isolation. This doesn’t mean we can’t dream of a resumption of some new form of normalcy, but for that to happen we need modeling that confirms the risk of doing so will not make our shared situation worse. Such talk of re-opening America for business has generated a great deal of recent conversation which is what I wanted to focus on in today’s update.
America being open for business is a catchy phrase but in the COVID-19 era it’s quite complicated. One way of thinking about the economic engine of the US is to think of the consumers and producers, and one way of measuring them is by age group. Amazingly the US population, divided into age deciles i.e., <10, 10-19, 20-29, … 70+, reveals the population to be near equal in each decile approx. 40mil.
- The first two deciles comprise 80 mil Americans, specifically those 19 and younger who have limited direct impact via the purchase or creation of goods or services.
- The last two deciles (age > 60), also 80mil, have limited contribution to the production of goods and services, but they do consume, especially in hard-hit market sectors like travel and leisure, retail, restaurant, and hospitality. Unfortunately, this group has such a high risk of devastating health outcomes if infected with COVID-19 that they will not be able to fully participate in an open America until there is a vaccine or its therapeutic equivalent.
- The remaining middle four deciles (160 mil), half the population, are the core of the economic engine and the group that might re-open America. Unfortunately, many of them have risk factors e.g., diabetes, obesity, chronic disease, smokers, etc., for whom participation may be too risky. Furthermore, many of this group are already working in market sectors that are not siloed by the pandemic because they are deemed essential or are using telework e.g., healthcare, technology, communication, e-tail, food production/grocery/drug store, logistics, government (military, police, sanitation), service e.g., electrical, plumbing, HVAC, landscape, construction.
- Of the remaining population aged 20-60, their personal risk from COVID-19 may not be much worse than influenza in a bad year, but their risk to those who are elderly or compromised may be significant.
All of this begs the question of who will re-open America and how can they mitigate risk effectively?
Mitigating risk requires more data than we currently have and that data requires testing not currently deployed or accessible. Those who are more than four weeks out from exposure to COVID-19, either asymptomatic or symptomatic, will likely have developed an immunity. Immunity can be proven with blood testing for appropriate IgM antibodies. A five-minute blood test by tabletop analyzer was just approved by the FDA, but projected capacity is only five million tests a year and we’ll need 10-20x that number.
- If immune, you have no risk of reinfection, but more importantly you can’t transmit. These folks can engage in the economy with abandon, they can also be on the front line directly engaging with those who are symptomatic with infection or at high risk. They can even donate plasma that can be used to treat the sickest.
- Those 20-60 y/o low risk who are not immune, but without active infection as determined by testing for viral RNA by nasal swab, could engage as their risk of serious complications from infection is low. However, should they become infected, they could transmit disease to others who are more vulnerable. Because of this, these folks need to be tested for active disease often e.g., weekly and, when positive, isolated.
Currently, too little time has elapsed to allow for a large segment of the population to be immune but this will change quickly in the coming two to three months. Hopefully, by then we will also have effectively deployed testing for both viral RNA by nasal swab and immune status by blood testing to make re-opening America, for at least a portion of the population, a safe possibility. When America re-opens for business we should be clear that this is not a return to the old way of doing business. America during the pandemic may be very different than the America we’ve known, but the America post-COVID is likely to be very different as well.
More thoughts on re-opening America in the two accompanying essays.
- We Can Safely restart the Economy in June. Here’s How: https://www.nytimes.com/2020/03/28/opinion/coronavirus-economy.html?referringSource=articleShare
- It’s Too Late to Avoid Disaster, but There Are Still Things We Can Do: https://www.nytimes.com/2020/03/27/opinion/coronavirus-trump-testing-shortages.html
Updated March 13, 2020
In the week since I last posted about the coronavirus disease, labeled COVID-19, it has landed on our shores. Thousands are likely infected and tens have died. It’s real, it’s here and it will be with us for a while. Information and misinformation about the spread and containment, speculations and accusations about the severity and response, continue to dominate headlines. I will once again try to provide a factual and rational summary of the current knowledge based on my analysis of CDC, WHO, FDA and other reports as well as insights from Infectious disease specialist colleagues.
- Name – COVID-19 is the disease caused by the coronavirus strain now dubbed SARS-CoV-2 despite the fact that COVID-19 virus is only 30% homologous with the SARS coronavirus. COVID-19 is not SARS but they are both coronaviruses
- Risk – Population tracking studies are beginning to clarify risk groups, and risk directly correlates with age and prior lung disease which includes smoking. Children < 15 appear to get mild if any symptoms. Young adults similarly get mild flu-like symptoms. Middle-aged adults, in particular male smokers, have more risk of severe consequences. Those over age 70, particularly those with chronic diseases, especially lung disease, may have as much as a 10% mortality risk. Immunosuppression e.g., cancer treatment, may not significantly increase risk.
- Disease Pattern – average time from exposure to symptoms is 5 days, symptom development after 12 days is rare, this is the basis for the 2wk self-quarantine if you’ve been potentially exposed. Flu-like syndrome (fever, aches, fatigue, dry cough) are the initial symptoms lasting 5-7 days. Shortness of breath, if it develops (20%), does so after day 7 – with a 50% chance of requiring hospital care.
- Testing – Among the most limiting factors impacting our current knowledge is the lack of available, rapid and accurate testing. Why we don’t have testing will be hotly discussed in the coming weeks and months but what’s important to know is that we won’t understand transmission and lethality without adequate population testing. Experts all hope that testing will be routinely available by 4/1
- Treatment – there have been few good-news stories since this crisis broke but one is Remdesivir, a broad-spectrum antiviral drug that is active against RNA viruses like Coronavirus. It was developed for SARS and Ebola. Like drugs, for AIDS it lessens viral activity and viral load. It may not be a cure but if the preliminary research is validated, taking Remdesivir at the onset of symptoms may prevent progression to the severe and potentially lethal respiratory disease that emerges in week two of infection.
- Containment – 30-second hand scrub is the most effective hand sterilizing technique. >60% alcohol sanitizers may work, some viruses like coronavirus are membrane-bound (i.e., norovirus is not), >60% alcohol disrupts the membrane and destroys the virus, but studies have not been done so only substitute is you can’t scrub. Clorox wipes, among others, will decontaminate surfaces but the surface must stay wet after wiping for 60sec ( e.g., plane seat/armrest/ tray), do not use on skin.
- Transmission – is person to person and infected individuals can transmit before they have symptoms. Without symptoms, they won’t be coughing in your face so masks don’t help but they may be shaking your hand with a hand that just touched their mouth, eye or nose. Don’t shake hands, try to keep a reasonable distance (6 ft recommended), wash your hands vigorously and often AND DON’T TOUCH YOUR HANDS TO YOUR FACE. Kids may not be at risk but they can be a vector for disease transmission, that’s one reason behind school closure.
- Understanding infectious disease spread may be scary but we need an eyes-wide-open approach, especially as our business will be critical to our nation’s success in dealing with this crisis. If no measures were taken to disrupt the spread then every 5 days each infected but asymptomatic person might infect two other people then those folks each infect two others and so on. If you apply exponential math based on 2000 infected folks in the US today, then there’d 1 million U.S. cases by the end of April; 2 million by May 7; 4 million by May 13; and so on. If only 10% needed hospital care that caseload would overwhelm our healthcare system. That’s why China, South Korea, and Italy essentially moved to national self-quarantine and it worked. That’s also why leadership today announced a no-travel policy.
Hopefully, testing, containment, and effective anti-viral therapies like Remdesivir will stem the tide of caseloads until we have a vaccine. AND DON’T TOUCH YOUR FACE!
Please see the following article from Vox – How canceled events and self-quarantines save lives, in one chart.
Published March 6, 2020
To My WCU listeners,
Like you, the continuously evolving news about Coronavirus (COVID-19) is incredibly unsettling for me, my family and loved ones. I find what I don’t know to be even more unnerving than what I hear and read. I’ve summarized my research to share with those I hold dear to help them confront this moment rationally and with the belief that being informed is being armed. Please share this with your friends and loved ones.
What’s the difference between a viral infection and the flu?
There are hundreds of thousands of viruses that infect nearly all living creatures. Many that infect humans are well-known likes measles, mumps, flu, and the common cold. A virus, like influenza, is not one thing, it’s more like a family of related viruses with each unique member of the family being just one strain of the virus, e.g., each year a new strain of flu requires a new vaccine
Unlike bacteria, which can be treated with antibiotics, viral infections are difficult to treat but they can be prevented with vaccines. If you get exposed to a virus your body’s immune system will keep a memory against it which prevents re-infection.
Vaccines mimic the body’s immune process by creating a memory but without the symptomatic infection. When a new virus emerges, usually because it jumps from an animal host to humans, no prior human exposure means no immunity in humans creating a risk for the virus to spread like wild-fire, which is called a pandemic.
What is COVID-19?
Coronavirus has been known for decades as a cause of the common cold, but in 2003 and again in 2012, two much more serious strains arose by jumping from animals to humans, they were called SARS and MERS. Fortunately, they did not spread wildly and were both quickly contained, but their lethality contributed to the initial panic reaction to the emergence of COVID-19.
The Coronavirus disease that emerged in Wuhan China in late December 2019, now called COVID-19, is such a virus. It is a species of coronavirus that jumped from bats to humans. We still don’t know enough about COVID-19: we don’t know how lethal it really is. The annual flu epidemic has a 0.2% mortality (2 deaths per 1000 infected). We know that because testing for flu is easy and available. Thus far COVID-19 testing is limited, and only those who are symptomatic and needing healthcare are being tested.
It may be that it is 10 times more lethal than typical flu OR it may be that 9 of every 10 people who get infected get no symptoms or just a cold, aren’t tested, and the mortality rates are overestimated. Lethality is also related to how easily the virus is transmitted. Unfortunately, we now think COVID-19 can be transmitted by infected people before they have symptoms like fever and cough.
Who’s at risk of COVID-19?
We are not all equally at risk. Most deaths have been in the elderly, frail and chronically ill. No reported deaths in children < 15. Since there is no specific treatment, and it may take 6-12 months to develop a vaccine, there are a limited number of things we can do as individuals, as communities, and as nations to limit the spread:
- quarantine communities where the infection is rampant (that might include travel restrictions, school closures or event cancellations)
- hand washing (sanitizing) and keeping hands away from your face so the virus doesn’t get into nose, mouth or eyes
- only wearing a high quality (N95) mask if in contact with those infected/coughing.
It may turn out that COVID-19 is no worse than a bad influenza season. But because this virus is new to humans, and we have so much more to learn, the fluidity of the situation is creating significant unease. As research answers more of the critical questions, I’ll provide updates as needed. Taking these preventative measures from the CDC is recommended.