Coronavirus Episode 5: We NEED to BEND the CURVE NOW

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Over the first four episodes in this coronavirus series, much has happened. In fact, this thing is evolving so rapidly that every day something unprecedented occurs that changes the calculus of how we’ll fare here in the U.S. So while I’ve introduced and backed up the concept that COVID19 is not as lethal as the media has made it out to be, there’s a catch. What the data is showing is that for this to be true, we need to “bend the curve”. Don’t do that and we become the nightmare of Italy, do it quickly and we could be more like Taiwan which is managing this crisis. So what does that mean and what do we need to do as fast as we can?

Two Very Different Mortality Rates for Coronavirus

We have two very different fatality rates published right now in the media on coronavirus. We have the crazy high ones usually in the 3-7% range that predominate news reports and then we have a few journalists who have been actually reporting a different dataset out of countries like Germany (0.2%) and South Korea (0.65%) where the fatality rates are all under 1% (2,3). Or the Diamond Prince Cruise that had a fatality rate in the older elderly of 1% (4). How can these two worlds co-exist? Let’s dig in on that today.

Why Is This Happening?

Remember, that I’ve been digging deep on the data being reported every day so you don’t have to do that. In that investigation, there seems to be one truism for this virus. Those countries who are prepared fare much better with similar mortality rates among the elderly as influenza, those who aren’t prepared produce a nightmare. So where does the U.S. stand this weekend? To answer that, we need to dive just a little deeper.

First, there are practical accounting issues that impact fatality rates. Second, since COVID-19 needs specific ventilators to effectively treat, there are practical health system issues that impact deaths.

The COVID-19+ Under Testing Problem

I’ve covered already in prior episodes that there is rampant under testing for the disease, even in countries where they have ramped up testing. Why? Because about half or more of people who come down with COVID-19 don’t get all that sick so many are never tested. This inflates fatality rates. See my past blog on that topic for more details.

Swamped ICUs

This is a problem we haven’t discussed as much in this series, but I did touch on in my interview with Dan Bongino which is below:

As I told Dan, the problem is that if 2-3% of the infected individuals need ICU care but no health system on earth is designed to deal with that kind of demand. Hence, if you want the same fatality rate as Taiwan or Germany, it’s all about preventing your ICUs from being swamped. That’s all about bending the curve.

What Is the Curve?

In epidemiology, during an outbreak, you can get a rapid spike in cases. As I’ve said before, some of that rapid spike that we’re seeing in the U.S. now is because we’re just starting to test, so we have cases in the community who have COVID-19 who have yet to be tested. So when early testing comes online, it looks like there is a rapid spread of the disease simply because you have lots of positive tests being reported. However, most of those people didn’t become infected yesterday, they just had a test today.

However, at some point, if people don’t change behaviors, even with COVID-19, which only infected 17% over a month on a cruise ship, the math is not on your side. Meaning an infected person can still have 100 close contacts in a month and even if only 17 of those get the disease, then you still have rapid spread.

While some of our “spike” in cases will be blunted by the burn out of the respiratory virus spread season in the northern hemisphere as I’ve discussed in past episodes, it’s still mid-March. So while the ability for respiratory virus spread goes down in March compared to February, it’s still a month where peaks can happen. Hence, we need to aggressively bend the curve down now so that we can get to April and May where the chance of spread is less.

What Does Bending or Flattening the Curve Mean?

While most will eventually get the virus, with bending the curve, you’re trying to push the bad cases into the future. For example, in the graph below I have two scenarios. One where the country does little to isolate people or does too little too late (the red line) and it gets many cases that require ICU care very quickly. This swamps ICU beds and ventilator supplies and people die because they can’t get adequate care. This is Italy right now. The green line is Germany, Taiwan, and South Korea, where they have ramped up testing and have isolated cases and shut down everything that can spread the virus. They are able to care for the few percent of patients that get very ill. Hence, their fatality rates are far lower. They have “bent the curve” downward and spread out cases over a longer time period.

Who Has Bent the Curve?

We have two examples to look at here. One I’ll call the Taiwanese approach and the other the Italy approach. One involves keeping the economy humming as much as possible while you control spread while the other wallops your economy. Let’s review.

Taiwan

As of this morning, even though Taiwan neighbors China, it has 53 reported cases despite widespread testing. That’s a tiny fraction per capita of China’s 80,824 cases. The country has also had one death compared to China’s 3,189.

Taiwan has had two prior viral scares come out of neighboring China. So they knew how to deal with this and had the infrastructure in place (1). Early on they spun up a command center tasked with dealing with viral outbreaks. They quickly ramped up COVID-19 test production. They began aggressively testing for the disease and isolating positive tests. They controlled their borders aggressively and put practical things in place like temperature monitoring stations at large office buildings and on borders. Anybody with a temp was told to go home and was flagged for testing. South Korea also did similar things. Hence they both avoided the spike in cases that the Chinese saw in Wuhan and as a country, they’ve been effective in controlling the virus

Italy

Italy didn’t do what Taiwan did. In particular, Italy was slow to act in getting rid of public events and likely because it’s so dependent on tourism, it didn’t address the problem head-on by controlling its borders. Like Wuhan, China, where the virus began, Italy got behind the curve and cases spiked. This quickly overwhelmed their health system and people have died for the reasons I discussed above. Swamped ICUs, not enough ventilators, not enough hospital space, etc…

Are We “Bending the Curve” in The US?

The good news is that we have had massive societal shutdowns this week. This includes everything from sports events to colleges. In my area, all public and private schools are closed. If we’re smart, we will begin to shut down all non-essential shops and restaurants like Italy eventually did. The problem is that Italy did this only two days ago, which is far too late. Like Italy, we need open grocery stores and doctor’s offices only. If we do these things by early next week we have a shot at bending that curve.

The BIG concern I see on this Saturday morning is that we are WAY behind on testing. It’s was my best-educated guess that by the end of this week the US would begin large scale testing for COVID-19. That didn’t happen. THIS IS A HUGE SELF-CREATED PROBLEM.

While some states like Colorado have begun to try to aggressively test, they are still hampered by a lack of preparedness in this area. Meaning they can’t get reagents and test kits at scale. In Seattle, the rule now is that if you have a fever or are sick, you need to quarantine yourself for 14 days, even though there’s only a 1 in 5 to 1 in 10 chance that you actually have COVID19. That’s not the way this should be done if we look at the countries that have done this well. Why? That shuts down the economy. By this time, Washington state alone should have tested tens of thousands of people. Only ten thousand or so COVID-19 tests have been performed to date in the entire United States and more than 1,500 of those have been done by Colorado. That’s NOT good.

Maybe a Bright Light on Testing?

The FDA just approved a new and faster Coronavirus test by Roche that can scale quickly (5). The company claims that 400,000 tests a week can be done at many different reference labs across the country. They also claim that they can get this started by next week. So could this be the large scale testing ability that we have needed for the past few weeks?

What Will Be the US Fatality Rate?

So if we want the less than 1% fatality rate in our old elderly similar to influenza, we need to start shutting down society as we know it. If we want to be Italy with a high fatality rate and a huge number of deaths that could have been prevented, then it’s business as usual. For example, in Colorado, our Governor is being aggressive and all of our public schools are shuttered. In Alabama, as of this writing, the public schools are still open. That’s a terrible mistake in my opinion.

What Can YOU Do?

Here’s what I now recommend:

  • Stay at home and self-quarantine for 14 days if you’re ill. Regrettably, we screwed up getting the needed testing ability to see if you have COVID-19. You likely don’t have it. However, you can’t risk spreading it.
  • Avoid spending face to face time with the elderly. They are the most at risk of serious consequences from COVID-19. Call them or facetime them so they don’t get socially isolated. Help out your elderly neighbors by grocery shopping for them.
  • Only shop at the grocery store and do the rest of your non-grocery shopping online.
  • Avoid any public events with 10 or more people.
  • Keep three feet back from everybody.
  • Wash your hands 10-20 times a day with soap and water for 20 seconds.
  • Wear a mask while around others if you have a cough. Surgical masks are not helpful if you don’t have this disease. Healthcare workers working around COVID-19 patients have better N-95 masks.

Why The Changes in My Outlook?

I thought that we would have widespread testing in place by now. We had an opportunity to begin testing on a massive scale and begin mass quarantining of positives. In that case, while public events would have been canceled, we could have kept our economy limping along like Taiwan. However, we blew that. Regrettably, that’s one where you don’t get a do-over. We will now have to do what Italy has done which is called, “SHUT IT ALL DOWN”. That’s the option where you temporarily wreck your economy while you try to control the spread of the disease.

The upshot? I’m sorry to have to be the bearer of bad news here. We all could have had an economy that was limping along while we contained COVID-19. However, because of the lack of testing ability at a critical time, we will have to take the shut down approach which is going to hurt. Could Roche’s new test really change the game? It’s possible if they can begin widescale testing early this next week. Meaning we will have to test between a quarter and a half-million Americans by this coming Friday to bend the curve down.

________________________

(1) Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan-Big Data Analytics, New Technology, and Proactive TestingJAMA. Published online March 03, 2020. doi:10.1001/jama.2020.3151

(2) Kolate G. Coronavirus Is Very Different From the Spanish Flu of 1918. Here’s How. The New York Times. https://www.nytimes.com/2020/03/09/science/coronavirus-is-very-different-from-the-spanish-flu-of-1918-heres-how.html Accessed 3/10/20

(3) The Local de. What explains the low coronavirus death rate in Germany? https://www.thelocal.de/20200310/what-explains-the-low-coronavirus-death-rate-in-germany. Accessed 3/12/20.

(4) Wikipedia. 2020 coronavirus pandemic on cruise ships. https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_on_cruise_ships Accessed 3/11/20

(5) Fortune Magazine. How Roche’s new coronavirus test sped its way to FDA authorization. https://fortune.com/2020/03/13/coronavirus-test-roche-covid-19/ Accessed 3/14/20.

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8 thoughts on “Coronavirus Episode 5: We NEED to BEND the CURVE NOW

  1. Jackie

    Asking for clarification on “while most will eventually get the virus”. Did you mean most people in the US will get the virus? And is this usual for a virus?

    1. Chris Centeno, MD Post author

      It’s estimated that 40-70% of Americans will contract this, but spreading it out over time means fatality rates stay low as the health system isn’t overwhelmed. That means that we need to “shut it all down” across the country now. Italy did that too late and they’re paying the price.

  2. Tk

    I guess I’m confused by the shift in opinion. Are there other factors to consider? What is the density of healthcare per density of person in these different countries? How does this affect whether healthcare will be swamped? How does population distribution affect virus transmission? How does population age affect the scenario? How are states in warmer climates faring? How could these factors come together to make conditions better or worse?

    1. Chris Centeno, MD Post author

      The single biggest issue right now is that if 2-3% of cases require hospitalization and ICU care and we allow a spike in cases because we don’t shut it ALL down (restaurants, shops, and everything else) then we will not have enough ICU beds and many more people will die. We don’t have much excess ICU capability. No more than Italy or Germany or S. Korea.

  3. Steve

    Great blog with good info. 6512 total deaths. Are ypu agreeing with that number ?

    1. Chris Centeno, MD Post author

      There is no way to double-check that number, but I will assume it’s right.

  4. Steve

    Yeah I see lots of websites with counters and last I saw they were showing 3.8 mortality rate which is much different that your view of it.

    1. Chris Centeno, MD Post author

      Again, this is discussed in detail in past blogs. There’s good news and bad news. The good news is that if we can keep ahead of this by testing and isolation, the countries that have done that and contained spread are reporting mortality rates in the 0.2-0.65% range. However, as the blog says, there’s a big “if” there. That’s if you have the ICU beds to be able to handle all of the cases. The only way that happens is if you get a lid on this and that’s something, so far, the US is reacting too little too late. We needed to be testing at scale last week and isolating positives. That didn’t happen, so we’re left with shutting it all down. For example, In Taiwan and S. Korea, they test at scale, have checkpoints for temps, track contacts and isolate aggressively. We’re not doing that yet so regrettably our only solution is to shut it all down.

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