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The Japan Experience: No mass shutdown. No mass isolation. Fewer cases and fatalities. What can we learn?

The big question that is on everyone’s mind is what is going to happen when America ‘gets back to business’ and people have the freedom to move about as they please.  It may take awhile before we get back to the freedom to work and live like we did just 3 months ago, but I am confident we will get there.  In the mean time, what can expect we in the next few weeks?  Of course, it’s impossible to know for sure, but examining how different states and countries have handled the infection may provide some insight into at least the breadth of things that might occur and provide some concepts we could use.s

I believe that looking at places where there have been less restrictions placed on the people AND where people have been less impacted (number of covid 19 cases and fatalities per million people) show us that we can live with open businesses where Covid 19 is no worse than the seasonal flu.  I believe that Japan provides an example.  I know we can’t mimic Japan in many ways, but there are experiences which we could learn from.  It is a story of how a different approach, mind set and cultural behaviors combine to give a final result.

Relatively little has been said about Covid 19 in Japan with its population of 126.7 million.  Most businesses have remained open, yet the Covid 19 infection and fatality rates are much, much lower than in the US (in the range of seasonal flu).  Some estimates are that less than 20% of Japanese businesses have been closed.

As of March 28, 2020, the Covid 19 stats for Japan vs the US are shown below. It is important to note that the US has done far more testing than Japan, but neither country has done much antibody testing, so the true infection rate is not known for either country.  Nonetheless, the statistics for Japan are very good. Covid 19. How many people are actually infected? Santa Clara County

 JapanUS
Population (millions)126.7340
Covid 19 cases136141,031,437
cases/million1083033
Cvoid 19 deaths38558705
deaths/million3177
tests150,6925,838,849
tests/million118917143

The difference in number of deaths/million people is dramatically lower in Japan than the US.

They used a ‘cluster-based approach’ to manage Covid 19..  The principal of this approach is that infection is spread from certain people being more contagious than others.  This concept was used to explain why many passengers on cruise ships are not infected despite having close contact with infected persons.

These more highly contagious people form clusters of infected people which go on to infect others.  Under this cluster based approach, each cluster of infections is identified and tracked to the original infection source(s) and these highly contagious people (and those they infected) are isolated.  This approach requires rapid targeted testing.  The government has a dedicated  department which does this monitoring.

This cluster-based approach is conditioned on clusters of infection get detected at an early stage.  In February 2020, a cluster based approach was used when an outbreak was identified in Hokkaido, Japan..  The source was located, containment measures employed (like closing all travel on/off the island, specific quarantine)  and the outbreak was rapidly contained.

It is noteworthy that South Korea used their version of the cluster based approach to contain their Covid 19 outbreak where they found 1 woman who infected over 1000 others and 60% of the cases in South Korea could be traced back to two churches.  Again, targeted testing and quick identification of clusters of infections were keys to success. South Korea: Covid 19 Containment vs Privacy

The Japan version of social distancing is called avoiding‘the three C’s’ : Closed spaces with poor ventilation; Crowded places and Close Contact places.  This is somewhat opposite to US instructions where we have been told to socially isolate but have closed parks, playgrounds and beaches.  Most, but not all Japanese elementary and high schools have closed, but the closures are only planned for 2-4 weeks depending on the local government.  It is not clear, school closures have (or will) influenced infections of fatalities given the relative low numbers of both.

There are also cultural practices that helped Japan limit the spread of the virus.  Large numbers of Japanese were already in the habit of wearing masks before Covid 19.  Western behaviors such as shaking hands, hugging, kissing and other forms of physical contact are not part of Japanese social behavior.  It is also interesting to note that on the famously crowded public Japanese transit systems, talking is considered to be poor etiquette so again, transmission methods are greatly reduced when no one is speaking and they are wearing masks.

Another cultural consequence of covid 19 isolation policy is suicide.  In Japan, the suicide rate has always been proportional to the unemployment rate.  Suicide rates have already increased in Japan even though the increased unemployment rate is still low compared to the US.  There is a real fear that Japanese suicide rates will increase dramatically if there is a US type of business shutdown.  Given the small number of Covid 19 deaths in Japan, it remains to be seen if the lives saved by sheltering in place are offset by lives lost due to suicide.

It is true  there has been an increase in the number of cases and deaths the past few days, but the numbers would have increase dramatically to reach the numbers of cases (108/million vs 2116/million) and fatalities in the US.  Due to these increases, this week, Prime Minister Abe declared a ‘state of emergency’ granting local governments power to make their own decisions about restrictions,  but there have been few nationwide mandatory shutdowns and only an appeal to ‘stay home’.  The state of emergency has also been set to be only 2 weeks long.  The Prime Minister’s opponents are calling for a larger shutdown but so far Abe has resisted.  Although the number of cases and deaths are increasing, Japan is still doing very well compared with most other countries it’s size.

Recent days have seen reports that some Japanese hospitals in major cities are running short of personal protective equipment. However, this may be a failure of poor planning and procedures rather than a failure of the cluster based approach.  The early success of the cluster based approach may have lulled the government into complacency and they failed to procure equipment and supplies when they could.  They are now playing ‘catch up’ to get supplies when they could have done so earlier.  Japan has far fewer ICU beds/100,000 people than the US and they are concerned about needing more ICU beds than they have, but they are not at that point yet.  The US has demonstrated that large numbers of hospital beds can be erected in short periods of time should they become needed.

The Japan model is based on geographic and social conditions which could be difficult to apply here.   However, I think there are clear experiences we can benefit from.

My summary is:

  1. You can limit the effect of the virus without mass shutting down businesses and sheltering in place as long as you have the ability to immediately identify outbreaks and identify and isolate the source of the cluster.
  2. Infections can be minimized by avoiding the ‘three c’s’: Closed in Spaces, Crowded Spaces and Close contact with other. Their version of social distancing.
  3. Infections can be minimized by reducing physical social greetings, kissing, hugging and handshakes.
  4. Mass transit can still be used if other behavioral changes are made.
  5. If you feel sick, stay away from others
  6. If you feel sick, do not go to work.

Japan is an example where people can live in an environment where Covid 19 is no worse than the seasonal flu (bad as that is) without a shutdown of the economy and staying indoors.  There’s always a chance of an outbreak in a closely packed country of 127 million people, but they have done well so far. Only time will tell if Japan’s approach was successful, but I am hopeful.

I am encouraging on our scientists and politicians to include the Japan experience in their thought and decision making process as they develop and implement plans to reopen America.

 

Reopen Businesses – What should the new ‘normal’ be?

Returning to normal…but what’s normal?

As the nation and the world turns toward reopening the world to business, there has been a lot discussion of whether we could ‘return to normal’, but what does that mean exactly and how do we know when get back to normal?  We have lived with numerous causes of death that are higher in number than we are seeing for Covid, yet we did not shut down our country for any of these other causes.  In other words, we accepted as ‘life’ that there are many things cause death but we continue to go through life without stopping.

We should not have to complete end or stop Covid 19 before we ‘return to normal’. ‘Norma’l includes yearly deaths many times that caused by Covid 19.

We get daily briefings and headlines about Covid new cases and new deaths from the US and around the world.  To date (April 27, 2020) there have been 1,004,942 Covid 19 cases and 56,527 deaths.  However, the view of the number of actual cases has drastically changed in the last week.  The availability of antibody tests, which can determine if someone has been infected, has resulted in several reports that the actual number of people that were infected may be somewhere between 16 to 80X higher than this value (up to 21% of the population).  This means the actual number of Covid 19 cases may in the range of 16,000,000 to 80,000,000.  This makes the fatality rate between .34 and .07%.  This is in the range of the seasonal flu. New York: Nearly 3 million infections – not 276,000

The early concern over Covid 19, which caused the nationwide lockdown were basically two concerns. The first was the seemingly high fatality rate which was generally reported to be between 5 and 10% back in March.  The second was the concern that the number of infected patients would overwhelm our health and hospital systems, and whether we could treat everyone who needed help.

As it turns out now, fortunately, neither of those concerns happened.  The fatality rate is most likely be well under 1% and may be in the range of the seasonal flu.  There was not one city, including the hottest spot, New York where there was a shortage of beds, intensive care units or ventilators.

The shelter in place and closing of businesses undoubtedly helped to slow the spread of the virus, but perhaps not as much as we previously thought.  Before antibody testing, we were operating under the fact the 1 million people had been infected.  In a country of 370 million, this would seem to say that the lockdown was very effective.  However, the antibody testing now suggests that the number of people infected may be as much as 80 million!  This means that the lockdown was not nearly effective as we thought.  It also means that the vast majority of those who were infected did not need hospital care and had no or minor symptoms.

As plans are being considered to how reopen America’s business, the question is what state of health are we going to return to or accept?

To try and answer this question, it is useful to examine the top 10 causes of death in the US in 2018.  The CDC reports:

CauseDeathsDeaths/100,000
Accidents1671,2748
Alzheimer's122,01931
Cancer599,274149
Diabetes8494621
Heart Disease655,381164
Kidney52,38613
Lower Respiratory (COPD)159,48640
Seasonal Flu5912015
Suicide48,3449
Covid 19 4/27/202056,527*15*
  • Covid 19 Numbers still increasing, but rate of increase has slowed

Note that as a society, we did not shut down our businesses or go into lockdown over these numbers.  In particular, it interesting to note that in the 2018 season, flu claimed more lives than Covid 19 has caused to date (although Covid 19 is sure to increase further).  We also did not stop driving cars even though over 100,000 per year die from car accidents.

It would seem reasonable that if Covid 19 statistics could be brought into line with these other causes of death that we would be back to ‘normal’.

A key factor to consider is that Covid was much more fatal to those over 65.  Currently 79% of the Covid 19 deaths were in people over the age of 65.  The 65 and older group represents just 16% of the population.  The data strongly suggests that those over 65 may suffer more fatalities.  The younger you are, the less likely that Covid will be fatal, even if you get infected.

When businesses open up, both businesses and individuals may have different behaviors depending on the age of the people involved.

Although, there has been a long and strong voicing that Covid 19 is not the flu, it acts more and more like a flu the more we study it.  It has been thought that Covid 19 was more contagious than the flu, but the recent finding that the number of infections known may be off by many millions, it is not clear how much more contagious it is.  As I always state, comparing Covid 19 to the flu is NOT downplaying the seriousness of Covid 19 – instead it is a reminder that the seasonal flu has always been deadly (25,000-60000 fatalities a season and up to 60 million infections) and will continue to be so.

I will discuss vaccines in an upcoming blog, but it is critical to note that the data regarding the seasonal flu is WITH an annual vaccine.  There is no current vaccine for Covid 19, so Covid 19 statistics should look much better once a vaccine is found.  However, it is very important to know that the seasonal flu vaccine does NOT always work well.  The effective of the seasonal flu vaccine has varied from 10 to 50% depending on the year.  Hopefully, the Covid 19 vaccine will perform much better.

Covid 19 Tests: What we can and can’t say.

Miami Dade: 165000 cases, not 10,000. More Good News

More good news.  It seems that each day, the results of another study of the actual extent of Covid 19 infection show that the actual number of people infected is much greater than we expected.

As always, this is good news.

Until now, Miami-Dade county in Florida has reported 10,600 cases of Covid 19.  However today, a University of Miami reported on a study designed to determine the actual extent of infection by selecting a wide range of patients with and without symptoms for antibody testing.

They found that 6% of those tested were positive for the antibody.  Assuming that their study group was representative of the Miami Dade county, this would mean that 165,000 were infected with Covid 19 instead of the 10,600 reported.  About 50% of the people tested reported having no symptoms for 14 days before being tested.

This data is consistent with the data reported for Santa Clara (2-5 %) and Los Angeles County (4%) in California and New York (up to 21%) as well as testing in Robbi Italy (10%) and Gangelt Germany (14%).  Although each study tested only a few thousand representative people, in all cases, the number of people tested ranged from 4 to 21% of the population- representing 10 to 80X the number of cases that have been reported.

This means that the ‘curve’ that we have been trying to flatten is NOT representative of the actual number of infections that have occurred.  Taking an average of 5% infection for discussion sake, this would mean that in the US alone, there have been 18,750,00 infections, not 953,851.  This would also make the fatality rate .28%.  If it turns out that 10% of the population was infected, the fatality rate would be .14%.  Recall that New York city reported an infection rate of 21%.

Caveat:  All of these studies represent cross sections of different areas of the US, Italy and Germany.  More data is necessary from many more places with wider demographic of study subjects until the actual infection rate is known.

However, even as we watch the daily count of new cases increase, it is certainly the case that the cases being measured are 10 to 80 times less than the actual number of people being infected.  Again, this is good news.  It means that 50-80% of the people who get infected have no or minor symptoms and that the fatality rate gets closer and closer to the values we associate with seasonal flu.  This is especially good news as the seasonal flu numbers are WITH a flu vaccine.  To date, there is no proven vaccine for Covid 19.  The numbers for Covid 19 can only improve with more antibody testing and the introduction of a vaccine.

This also has implications on reopening businesses as sheltering in place may have been effective, but perhaps not nearly as effective as it was thought to be.

New York: Nearly 3 million infections – not 276,000

New York: Infection rate 10x higher than previously thought.  This is good news.

New York reported their first results in larger scale antibody testing to see how many people may have had actually had a Covid 19 infection.  43% of the tests were conducted in New York City while 32.8% of the test were taken out of the city.  The presence of the antibody means the person had and recovered from Covid 19 infection.  In most cases, the person was unaware they were infected.  This is GOOD NEWS.  It means that most people who get infected have no or minor symptoms and it makes the fataility rate (the % of people who die after getting infected) much, much lower.  See my earlier blog on antibody testing. Covid 19 Tests: What we can and can’t say.

The results reflected large differences between different areas of the state.  The number of people who tested positive for the antibody was:

New York City: 21%

Long Island: 16.7%

Westchester 11.7%

Rest of New York 3.6%

This corresponds to 1.7 million people in New York City and more than 2.6 million statewide who have been infected.  These number are much, much higher than the 275,000 confirmed cases that his reported today.

The tests show that the spread of covid 19 was not very different for different age groups:

  • 45-54 age: 16.7%
  • 65-74 age: 11.9%
  • Over 75 age: 13%
  • Less than 45 ranged from 8 to 15%

It is reminded here that this is percentage in each age group that had the antibody – they are the survivors.  The fatality rate among the groups is very different, with those over 65 accounting for 40% of the deaths.  The fatality rates will be discussed in a future blog.

Black, latino and multiracial New Yorkers had a 22% average positive tests while White accounted for 9.1% of the positive results.  Although it is clear there is a racial component to the infection rate, strict comparison of the numbers should be done carefully, as most of the testing was done New York City which has more minorities.

Importantly, this make the fatality rate around .5%, 10x lower than what was known just a couple of weeks ago.

This does not negate the severe impact the disease has had on the public but it does provide more insight into the disease.

The results here are consistent with other immunity tests reports in Santa Clara County, Los Angeles County, Robbi, Italy and Gangelt Germany and continues to indicate that the fatality rate of Covid 19 is likely to be significantly under 1%. Covid 19. How many people are actually infected? Santa Clara County 

Caveat:  This study and others should be considered preliminary studies.  They clearly show a high number of infections but only in limited locales.  Much more data from more locations and wider demographic inclusion will be necessary before the actual numbers of infections are known.  The results may also vary from country to country or county to county.  However, all indications so far are that the number of infections  determined by antibody testing is far higher than the number of confirmed cases being reported.

 

Texas and Georgia Hair Salons Opening: Would you go?

This week, several states like Georgia and Texas are beginning to cautiously allow the opening of selected businesses.  They are doing this in the wake of the Federal Guidelines for reopening their businesses which provides guidelines for reopening but allows local governors to make final specific decisions. I’m going use the opening of Hair Salons as my discussion focus because it is controversial but brings out all the complexities of reopening a business.

In the past month, grocery stores, pharmacies, big box stores and Home Depot have opened without starting any outbreaks – this suggests that other businesses may find ways to reopen and stay safe as well.  It is hopeful that gyms, schools and other places can find ways to open and operate safely.

It should be emphasized that within a state the infection rate of Covid 19 can be very different. This means that you should know the situation around where you live.  Some areas have much higher rate of infection and people should behave accordingly.

Texas.  For instance, in the last 14 days 155 of the 255 counties of Texas have not reported any cases of Covid 19.  Another 19 counties have reported less than 10 new cases of Covid 19.  This is in contrast to the largest county, Harris and Dallas counties which reported 754 and 556 cases respectively in the same time period.  Just 10 counties account for 72% of the Covid 19 cases in Texas.  However, on percentage basis, on average 1.2% of the population of each county has been infected.  Keep in mind that this is a lower percentage that catches the seasonal flu.  Your risk of getting the disease is highly variable in Texas (and everywhere else).

Similarly the 10.6 million people of Georgia live in one of 158 counties.  The top 10 counties account for over 55% of cases.  It is a much different environment in Dekalb County (1600 cases including Atlanta) than in Montgomery County (2 total cases).

The reopening of businesses is not only economically crucial but also crucial to the health of the general population.  Over 50% (some higher) of the people live paycheck to paycheck and lines for food banks are enormously long.  Also, ‘elective’ surgeries and medical treatments have been stopped but the long term health implications of these stoppages are not yet known.  For instance, cancer screening stopped so there are people who may have been able to be diagnosed with cancer and start treatment have been waiting over a month just to get the diagnosis.  People with chronic pain are also not being cared for during this time.  A topic for another blog will be the costs involved.  BEFORE the over 5 trillion dollars recently allocated by congress, the national debt was 18 trillion dollars which translates into an interest payment of approximately $500 Billion each year.  That is $500 billion that could be spent on other things like education, homes, health care etc….the new spending will send our interest payments to over $600 Billion/year – over 10% of the US budget.

On the other hand, no one wants to ‘reignite’ the infection of Covid 19 after working so hard and making so many sacrifices to get the disease under some management so it will be balance to get back to work and stay safe.  I’m sure there will be some good decisions and some bad decisions in the coming weeks. Choices have to made on imperfect and incomplete data and the interpretation of the data we do have can often be interpreted in different ways.

It is important to emphasize that in these states that are beginning to allow businesses to open – it is NOT business as usual.  Social distancing guidelines remain in effect and there are many more procedures that must be followed in order to reopen and stay open.

One of the big controversies is the opening of hair salons.  It seems that this puts two people closer than social distance guidelines.  Is this a good idea?  The first answer is, that we don’t know how this will work – especially if they follow the guidelines.  This may be too much detail, but it illustrates the details that have to be taken for ANY business to reopen.  Here are the Georgia Guidelines for Hair Salons.  Also, consider that everyone should use some common sense along with government guidelines.

If you feel sick – don’t go out. 

If you’ve been in close contact who has been sick, don’t go out. 

If you feel sick – don’t go to work.

If you have been in close contact who has been sick don’t go to work.

Be mindful of exposing others to risk.  Most recent data suggests that 80-90% of infected people have few or no symptoms but can transmit the disease to others.  So even if you are feeling good, be mindful of who you come into contact or close proximity with.

Also, getting testing for Covid 19 just tells you if you have been infected on that day.  If you were recently infected, you may not have had the time for the infection to become detectable.  The test also will not tell you if you get the virus the next day or anytime in the future.  If you feel like you might be sick – stay away from others (test or no test).

Look the hair salon guide over, consider where you live and decide if you would go to hair salon if you were in need of a hair appointment.  I know this is only a small segment of life, but the same decisions will have to be made for every business that opens and every business you frequent.

Salon Guidelines – Georgia

  • Salon/shop employees will be required to wear masks at all times. Salons may want to consider providing masks to clients. Clients should wear face masks to the extent possible while receiving services.
  • Salons/shops should also make use of face shields, gloves, disposable or re-washable capes, smocks, neck strips, etc.
  • These items should be disinfected or disposed of between each client. Employees should should arrive at the salon/shop showered and wearing clean clothing and change clothes before leaving the salon/shop each day.
  • Hand washing with soap and warm water, for a minimum of 20 seconds will be required by employees between every client service.
  • All salons/shops should be thoroughly cleaned and disinfected prior to reopening. Disinfect all surfaces, tools, and linens, even if they were cleaned before the salon/shop was closed.
  • Salons/shops should maintain regular disinfection of all tools, shampoo bowls, pedicure bowls, workstations, treatment rooms, and restrooms.
  • Additionally, salons/shops should remove all unnecessary items (magazines, newspapers, service menus, and any other unnecessary paper products/decor) from reception areas and ensure that these areas and regularly touched surfaces are consistently wiped down, disinfected, and that hand sanitizer is readily available to clients and staff.
  • Avoiding the exchange of cash can help in preventing the spread of the virus, but if this is unavoidable, be sure to wash and sanitize hands well after each transaction.
  • The use of credit/debit transactions is preferred, using touch/swipe/no signature technology.
  • Employees who are sick will be expected to stay home.
  • Salon/shop owners/managers should provide training, educational materials, and reinforcement on proper sanitation, hand washing, cough and sneeze etiquette, use of PPE, and other protective behaviors.
  • Ensure break rooms are thoroughly cleaned and sanitized and not used for congregating by employees.
  • Be flexible with work schedules/salon hours to reduce the number of people (employees and clients) in salons/shops at all times in order to maintain social distancing.