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Covid 19. Schools reopen? Yes or No?

One of the greatest points of disagreement in the media, politics and at home is over the reopening of schools.  On one side of the discussion is that school is critical to the development and well being of children.  Schools provide instruction in important subjects, develop social and emotional skills, safety, reliable nutrition, mental health therapy, physical activity and also allows parents to go to work.  The other side of the discussion is if reopening of schools is safe for the children, teachers and general public.

There are many countries that have reopened their schools and their methods and results should be lessons for the US. https://www.usnews.com/news/best-countries/articles/2020-07-22/how-countries-reopened-schools-amid-the-coronavirus-pandemic

In summary, many countries have demonstrated that it is possible to open schools without causing spikes in cases and more importantly without causing spikes in deaths.  Children are 8 X more likely to die from fly/pneumonia than covid 19.

Denmark was one of the first countries to reopen schools after they shut them down.  Denmark reopened their schools on April 15 for children 2-12.  The measures they implemented appear to be successful as there has been NO increase in covid 19 cases and no serious outbreaks in schools.  On May 18 those aged 12-16 were allowed to return to using the same protocols.

Similarly, schools in Germany, Finland and Norway have reopened without significant spikes in the number of new cases and more importantly, no increases in deaths.

South Korea and Israel are examples of countries that reopened, closed and reopened  In both cases, there was a general increase in the number of covid cases that coincided with the reopening of schools.  However, in neither country was in shown that it was the reopening of schools that caused the general increase in covid.  In both counties other restrictions to the public were also lifted at the same time schools was reopened.  For instance, in Israel, groups of upto 250 were allowed to meet at the same schools reopened.  Schools are now open in both of these countries.

The big question everyuone is asking is “is it safe for children to return to school?’  Often this question is  addressed by the number of children who may become infected.  Although, no one wants any child to get sick, the facts are that people (and children) under the age of 26 have a significantly higher risk of dying from flu than dying from covid 19.

From 2007-2017, 172 million people died from flu and pneumonia.  This is an average fatality rate of 60,000/year.  However, the real detail is in the age of the people effected.  By the numbers, children between 5 and 14 have a 1 in 200,000 chance of dying from fly/pneumonia but a 1 in 1.5 million chance of dying from covid 19.

The following shows the relative risk of death from covid 19 vs pneumonia/flu.  Note that those under the age of 15 have 4 to 9 times higher risk of dying from flu/pneumonia than covid.

Evidence is mounting that children are less susceptible to Covid 19 and are less likely to transmit the virus to others.  When children under 15 test positive for covid 19, almost 40% have no symptoms and majority develop fevers and fatigue but recover. https://pediatrics.aappublications.org/content/145/6/e20200702

The data from around the world is consistent in showing that children are at lower risk from covid than from the flu.  However, there are still concerns about the risk to teachers, staff and student families.  It is likely teachers and staff will be the sources of infection, not the victims.  The results from many countries who have reopened their schools since April and May clearly show that there are ways to reopen schools without causing an increase in the number of cases or the number of deaths due to covid 19.

The current CDC estimate is that the overall fatality rate of covid is .65%.  However, this number is dominated by the fact that the fatiality rate of people over 65 is 5.6%.  The fatality rate of those under 64 is lower than that or flu/pneumonia.

The fatality rate of children who tested positive for covid is .03%.  Or, 99.7% of children who get covid 19 will recover.  This fatality number is much lower than many other diseases and causes for children.

As a last calibration, it is interesting to note that even in this year of the global pandemic, there are still more deaths attributed to pneumonia/flu than covid 19.  Covid 19 is to be respected and avoided but our overall understanding of the disease, use of social distancing, masks, testing and improving treatments have lowered the fatality rates down to levels of other diseases that we have learned to endure without shutting down our society. https://freopp.org/estimating-the-risk-of-death-from-covid-19-vs-influenza-or-pneumonia-by-age-630aea3ae5a9

Covid 19. Cov 19. Impact on Health Care

Although it is appropriate that almost all the news about Covid 19 is about new cases, and the second wave, there is not much said about how the covid 19 policies that limit medical treatment are effecting the population.  The short answer is that there is likely to be a very large consequence for not going to the doctor for checkups, diagnostics and elective surgeries.  It is estimated that, between March and June,  more than 80,000 cases of the five most common cancers in the US will not be diagnosed because of covid 19 disruptions in elective treatments.  Screenings or breast, prostate, colorectal, cervical and lung cancer were down 39-90% during the week ending on April 10.  The delay in diagnosis and treatment can result in as many as 34,000 excess deaths due to cancer in the US.

Additionally, the number of admissions to oncology outpatient clinical have decreased up to 50%.  It is expected that the majority of the cancers not diagnosed will be breast cancers.

Cancer screenings generally take place in a doctor’s office or at diagnostic centers run by larger health systems.  However, there has been great variability system to system, state to state on how these facilities have responded to cancer screenings due to covid 19.  Some have simply closed, while others open for ‘emergencies’ only.

Cancer patients may be longer term, and somewhat hidden consequence of covid 19.  This is a lot of people not getting cancer diagnoses.

In a more general sense, it is estimated that there will be 28 million who will have had their surgeries cancelled because of covid 19.  The long term health consequences of delaying these surgeries is yet to be determined.  This corresponds to over 70% of all elective surgeries being cancelled.  Of these surgeries, an estimated 2 million will be cancer related surgeries.  Elective surgeries have an extraordinary influence on hospital revenues.  In many large hospitals, elective surgeries account for nearly 50% of the revenue.  The loss of elective surgeries deprives hospitals of their largest source of income.

In the UK, it is estimate that over 40,000 surgeries are cancelled each week elective surgeries are not allowed.  It could take well over a year to catch up on the backlog of surgeries.

It is estimated that there has been up to a 70% decrease in patient visits to doctors from February through April.  In the past month, this has rebounded to the level where there are 30% fewer visits to the doctor than in February.

The moratorium on elective procedures jeopardizes the financial integrity of health care systems that are disproportionately reliant on elective procedures as a revenue source. In response, the U.S. Congress passed the Coronavirus Aid, Relief, and Economic Security Act (CARES), a $2.2 trillion bill with $100 billion designated to hospitals and $350 billion designated to small businesses including private orthopedic practices . Although these relief programs may alleviate some of the economic burden, the legislation is not comprehensive, and it will not resolve all financial losses accrued by health care systems and orthopedic practices. Without the revenue from elective procedures, many orthopedic practices have had to furlough employees and withhold surgeon salaries. Mayo Clinic has announced a projected $900 million shortfall, with employee pay adjustments and furloughs .

 

Covid 19 Testing. The good, bad and unknown.

One of the most talked about issues around Covid 19 is testing.  Everyone seems to want a test.  However, little is said about the details of the tests, such as kinds of tests, good/bad tests and what do you do with the results.  The answers to these questions will help answer the questions about how important the tests are to reopening of businesses of keeping a business open.

A reliable, fast diagnostic needs to be established and available to manage the reopening of businesses.  The ability to identify infections before they become clusters, or clusters before they become outbreaks will be significant in how successful we will be in reopening businesses.

The tests.  There are two kinds of tests being talked about in the news and the reporting does not always make it clear which test they are talking about.  In most cases, they are talking about a DIAGNOSTIC test.  A diagnostic test will determine whether or not the Covid 19 virus is present at the time of the test.  The other kind of test is generally termed a serology (blood) test.  The serology tests determine the presence of antibodies that are created if the patient had been been previously infected with Covid 19.

Diagnostic Testing.  Most diagnostic tests use a method abbreviated RT-PCR (Reverse Transcription-Polymerase Chain Reaction) that will detect the presence of the DNA from the virus.  There are several manufacturers of these tests around and THEY ARE NOT THE SAME in reliability.  The difference in testing methods and reliability should be remembered when analyzing data from different sources.

In most cases, the testing being discussed are the results of diagnostic testing.  That is, diagnostic methods are used  when the daily number of confirmed cases is provided.  For instance, diagnostic tests were used to report the 1,391,316 confirmed cases of Covid 19 in the US (5/12/20).

A diagnostic test will determine if a virus is present at the time of testing.  It can not tell if the person was infected and then recovered nor is it predictive of if the patient will get the disease tomorrow or any time in the future.    If you are showing severe symptoms, you should go get medical attention whether or not you have been tested.  If you are feeling ill in any way, you should stay-at-home regardless of whether or not you are tested.  If you test negative, there are also uncertainties.  You may have been infected just before the test and the virus has not spread enough to be detected, or you could get infected tomorrow.  If you have no symptoms but are positive in a diagnostic test, you are among the 80% of infected people who have no or minor symptoms.

Serology – Antibody Testing

Serology tests are blood-based tests that can be used to identify whether people have been exposed to Covid 19 by looking for specific antibodies.  The mechanisms for antibodies was topic of an earlier blog regarding vaccines.  Covid 19 Vaccine. Where are we in the process? How will they work? What’s taking so long? The presence of antibodies would indicate that the patient had been infected with Covid 19.  As mentioned above, because the vast majority of people who are infected have no or minor symptoms, antibody testing is the only way to determine how many people are actually infected.  Earlier blogs have indicated that the actual number of people infected as determined from antibody testing is up to 20x higher than the number of infections detected with diagnostic testing.New York: Nearly 3 million infections – not 276,000

It is important to know:

  1. It is not known if the presence of antibodies makes the patient immune from further infection.
  2. If the patient does become immune to Covid 19, it is not known how long the immunity will last.
  3. The immediate benefit from antibody testing will be to determine how many people were infected.

Specificity and Sensitivity.  These are KEY factors in the reliability of tests but are seldom discussed in the news.   Specificity is a measure of how reliable the test is.  In other words,  if the test indicates you have the disease, do you really have the disease?  Or is the test somewhat unreliable because it can provide a positive result when you don’t have the disease.  This is termed a false positive result.    Specificity is a measure of how many false positives a test will give.  A test with a specificity of 80% means that only 80% of those who tested positive actually are positive.  20% show an incorrect positive result.

Sensitivity is a measure of how reliable the test is, if the test says that you are negative.  It is a measure of the false negatives.  A test with a sensitivity of 90% means that 90% of the people who test negative, truly do not have the disease but 10% of the negatives are really positives and have the disease.  Some of the reports from South Korea suggests their test had a sensitivity of 80-85%.

Each test should be evaluated for both it’s specificity and sensitivity.  It is possible for a test to have a high specificity but a low sensitivity.

These seem like details, but a 5% false negative means that if 1,000,000 people test negative, there are really 50,000 people who are actually infected.  Labs, doctors and patients should be very aware of the specificity and sensitivity of the tests they are administering.  There are over 20 different tests being conducted around the world, each with it’s own, sometime unknown specificity and sensitivity.  This makes comparative data very difficult.

As the choice of what test to run is determined locally (state, county, hospital), differences in specificity and sensitivity between tests likely exist.

There is an old joke in testing labs about what level of service a client can request. For each test, you can choose how fast you get the results back, how accurate the results are and the cost of the test.  Unfortunately, you can only choose two of the three choices.  This is true for Covid 19 testing as well.

Test Approval Process.

It would normally take more than a year or more to get a diagnostic test to get FDA approval.  This is because of the number of patients and time in clinical trials that are required to demonstrate sensitivity and specificity.  Under the FDA Emergency Use Authorization guidelines, manufacturers only need to test 30 laboratory samples and demonstrate 95% specificity (positives) and 100% sensitivity (negatives).  That means that the test must detect 95% of the samples that contain the virus.  A 100% sensitivity means that there can be no false negatives.  I am unaware of any test whose accuracy has been evaluated by an independent organization (eg not the company who manufacturers the test).

For diagnostic tests, it is important to know that the virus used in these laboratory tests are not from patients but from lab sources.  It is also not clear that all labs are using the same concentration of virus in all of their tests.  Last, the tests are conducted under laboratory conditions without issues of sample collection and other factors present when testing patients.  There is no requirement that any clinical data from patients be part of the Emergency Use Authorization approval process.  This does not mean that the tests are unreliable, it just means the tests have not been as fully evaluated as they would have in an non-emergency environment and we don’t know the number of false positives and negatives we are getting (other than the data supplied by the manufacturer).

There are also factors not related to the actual diagnostic test that can effect the test results.

  1. When the patient was infected.  If the patient was infected very recently, there may not be enough of the virus to detect.
  2. Where the virus is. Most tests are from nasal swabs.  However, as the disease progresses, the virus moves into the lungs, so the viral load in the nasal passages goes down.
  3. Incorrect sample collection. If the nasal swab is too superficial (not deep enough) then the virus may not be detected.
  4. Rapid testing after collection. The tests usually must be run within 8 hours, unless it is refrigerated in which case it much be tested within 72 hours.  Testing outside the windon decreases the chance of detection.

More attention must be paid to determine the specificity and sensitivity of all tests.  Too many false negatives will release infected people into the population and too many false positives can overwork or overload the health care system.  The situation is made more difficult with the increasing number of new tests being introduced in the US and around the world.

The same specificity and sensitivity issues apply to the Serology-antibody tests.  Again, there are over 20 different tests of this type being run around the world.  Like the diagnostic tests, they are being approved for use under emergency use authorization so specificity and sensitivity values are being supplied the manufacturer who makes the tests under laboratory conditions.  This does not make the tests unreliability and I am not criticizing the manufacturers, but independent evaluation under normal clinical evaluation guidelines should be done.

It is a difficult time as development and distribution speed is now prioritized over normal safety and effectiveness procedures.  This undoubtedly has allowed the use of some tests that would not have been approved under more normal conditions.

There are two examples of what can happen if specificity and sensitivity are not well established.  In May, the United Kingdom reported that it had purchased 2 million antibody test kits from China for $20 million (₤16 million).  However, the purchase was apparently made before independent UK analysis was done.  When the kits were received, independent tests showed both too many false positive and too many false negatives.  The 2 million kits are useless. https://www.bloomberg.com/news/articles/2020-04-07/new-test-hopes-dashed-as-u-k-finds-antibody-kits-don-t-deliver

The city of Laredo, Texas also bought 20,000 antibody test kits from China for $500,000.  These kits were not approved by the FDA in any way.  The city took a risk to secure antibody testing.  Once received, the tests, like the ones purchase in the UK, turned out to be unreliable and useless.  The kits were, nonetheless, seized by the FDA.

It is not my intention to criticize the incredible speed at which these highly complex tests are being developed. I have not discussed the actual technology, but it is quite incredible.  We usually just see a box or a device without knowing the complex test that is going on inside.   The balance of speed of development and reliability is a point the world is trying to find.  The purpose of this blog is to discuss the factors involved in testing that have not been often discussed and to provide some background to the daily news regarding testing.

 

 

 

 

 

 

 

Covid 19 vs Spanish Flu: A Societal Comparison

Although a century apart there are often comparisons made between the Spanish Flu of 1917-18 to today’s Covid 19 pandemic.  Often, the experiences of the Spanish Flu have been mentioned/used as justifications or reasons behind Covid 19 policies.

Despite being the epidemic that caused the most American deaths, the details of the Spanish Flu are not well known and the details of how the disease was handled are even less well known.  This blog provides a brief summary of the history, effects and management of the Spanish Flu, and the lessons that can or can’t be learned from the experience.  This discussion will not compare the technical differences between the two diseases.

The actual number of cases and deaths due to the Spanish Flu are not known because of relatively poor record keeping at the time, it was a global pandemic and it happened in the midst of World War I.  However, many estimates indicate over 500 million people worldwide were infected and somewhere between 30 and 100 million died.  In the US, it is estimated that 25 million (28% of the population) were infected causing 670,000 deaths.  In contrast with Covid 19, the Spanish Flu was most deadly for those ages between 20-40.  The mortality rate for 15-34 year olds in 1918 was 20x higher than any other previous year.  The mass movement of millions of soldiers and conditions of World War I contributed to the wide spreading of the disease.  An estimated 50% of the US soldiers who died in Europe during the war died from the Spanish Flu.

This is a long blog, but if you read on, there are 5 sections.  The history section is a bit long but you can skip down to the other discussions as your interests guides you.

  1. History of the Spanish Flu
  2. How the Spanish Flu was handled by the Government
  3. 1917 vs 2020.
  4. Quarantines
  5. Lessons Learned

History It is important to note that Spanish Flu happened during World War I. At the beginning of World War I in 1914, President Woodrow Wilson declared that the US would remain neutral in the conflict.  However, in 1917 there were a series of incidences of involving US lives and ships being destroyed by Germany which led to the US declaration of war on April 2, 1917.  However, preparation of US troops was well underway before the declaration was made.  The war would play a large part in spreading the disease around the world.

It is not specifically known what the original source of the Spanish Flu was. That is, it is not known where the first case in the world appeared.  There are theories that the disease began in France in 1916 or China of Vietnam.  Many theories also suggest that the disease could have started in the US (although it is not known how it got to the US).  One of the earliest (some say the earliest) report of this disease was January 1917 in Haskell County, Kansas.  An outbreak of an unknown disease was so severe that it was reported to the US Public Health Service.  This is believed to be one of the first recorded notices anywhere of an unusual respiratory disease.  Several men from Haskell went to a military, Camp Funston in central Kansas.  On March 4, days after they arrived the first soldier known to have the what we now call the Spanish flu, reported ill.  Within 2 weeks, over 1000 soldiers on the base were admitted to the hospital with thousands more sick in the barracks.  38 soldiers died.  It is likely that infected soldiers from here infected 24 of 36 large training camps, sickening thousands and killing hundreds.  Many of these infected soldiers then brought the disease to Europe.  In June 1917, 14,000 US troops landed in France. By May 1918, a million US soldiers had landed in Europe.  By the end of the war on November 11,1918 more than 2 million American soldiers had served on the battlefields of Europe.

The ‘first wave’ outbreak at Camp Funston and in Europe through early 1918 did not cause serious concern because although many were infected, there were relatively few deaths.  For instance in 1918 the British Grand Fleet reported over 10,000 sailors had fallen ill but only 4 had died.  It was not until the King of Spain, Alfonso XII, contracted the disease that the disease became noteworthy.  Spain was also neutral in the war and was free to publish information about infections without censorship from other countries.  Because most of the early detailed reports were from Spain, it became known as the Spanish Flu (even though it did not begin there.)

In August 1918, the second wave, more deadly than the first, began in areas of Europe.  It is speculated that the ‘first wave’ virus had mutated into a more lethal version.

In late August 1918 military ships departed from the English port of Playmouth carrying troops with a virulent form of the Spanish Flu and went to cities like Brest, France, Boston, USA and Freetown Africa.  In Boston, shortly after their arrival sailors and civilians marched together through the streets of Boston for a ‘Win the War Rally’.  Soon, the surrounding Boston area and New England would feel the full force of the disease.  In September 1918, a Navy ship from Boston carried infected sailors to Philadelphia.  Although sailors began to die within days of arriving at Philadelphia, city officials did not truthfully report the deadly disease.  In fact, they publicly dismissed the seriousness of the disease and  on September 28, they famously held a large parade in the middle of the city attended by an estimated 200,000 people.  Within 72 hours of the parade, every bed in Phialdelphia’s 32 hospitals were filled and in a week, 2600 Phildadelphians had died of the Spanish flu.  A week later another 4500 had died.  By March 1919, over 15,000 Philadelphians had died from the disease.

The disease spread all over the country from the Atlantic to the Pacific and from Canadian to Mexican borders.  Spain, Britain and France were all particularly hit hard with the disease but the disease also spread to Asia, Africa, South American and the South Pacific.

It is highly likely that the war conditions contributed significantly to the spread of the disease.  First, millions of soldiers from the US were transported to Europe.  Once in Europe, soldiers and civilians were often in cramped, damp and crowded conditions making the spread of disease easy.  The poor sanitation and malnutrition also helped to spread the infection. Further, there were vast movements of people both civilian and military due to fighting. During the summer of 1918, many troops returning home brought the disease back to the countries they came from.    All of these factors likely contributed significantly to spread of the disease.

It is interesting to note that is speculated that President Woodrow Wilson was infected during the Versaille Peace Conference at the end of the war.  This possibly contributed to Wilson accepting some surprising terms in the treaty.

Overall, the Spanish Flu is likely to be deadliest epidemic in the history of world.  Estimates are that 1-3% of the world’s population died from the Spanish Flu.  So many younger people died in the US in 1918 that the average US life expectancy was reduced by 10 years.

It is not clear why the second wave of the virus was so much more lethal than the first.  There is some speculation that there may have been a mild and deadly version of the virus, but this has not been definitively confirmed.  In the ‘developed’ world, the mortality rate was generally believed to be about 2%.  In other counties, the mortality rate has been estimated to have caused up 14% of a population (Fiji islands) to die.

Eventually, toward the end of 1918 the number of deaths caused by the virus began to decrease.  This is believed to be because there were so many people that had already been infected and/or the virus may have mutated again to be less invasive to the lungs.  It eventually ‘devolved’ to be part of the seasonal flu.  There was never a vaccine developed for the Spanish Flu.

https://www.smithsonianmag.com/history/journal-plague-year-180965222/

How was the Spanish Flu handled by the state and federal government? There was no national policy for dealing with the Spanish Flu. It was left to the states to come up with how and when to deal with the disease.   It was common practice for politicians, administrators and those responsible for the public safety to deny, deceive or out right lie about the dangers of Spanish Flu. City and government officials did not disclose the danger to the general public so that public spirits would not be diminished and that support for the war would be encouraged.  That’s why the parades in Boston and Philadelphia were held despite the fact that city officials were aware of the potential danger from the Spanish Flu.

There was policy that started with President Woodrow Wilson that authorized, even encouraged lying to the public.  When the United States entered the war, Woodrow Wilson created the Committee on Public Information, which was inspired by an adviser who wrote, “Truth and falsehood are arbitrary terms. The force of an idea lies in its inspirational value. It matters very little if it is true or false.”

Official government posters and advertisements urged people to report to the Justice Department anyone “who spreads pessimistic stories…cries for peace, or belittles our effort to win the war.”  The real fatalities and illness of the Spanish flu fell into this ‘pessimistic story’ category.

An example of this is that the director of Public Health in Philadelphia, continually reassured the public that the illnesses being reported were ‘contained’ or would be decreased and that it would ‘nipped in the bud’.  Under these misdirections,  he authorized and put on the large parade that infected thousands of Philadelphians.  Across the country, the lie that disease was nothing to worry about was commonly told my officials.  This lie was told in large cities like New York and Los Angeles as well as less populated areas like Arkansas.  Even the U.S. Surgeon General Rupert Blue said, “There is no cause for alarm if precautions are observed.”

Eventually, the people caught on because the true effect of the Spanish flu could not be hidden.  For instance, 53% of San Antonio, Texas got infected and death could come quickly and dramatically.  It was also evident how serious the disease was when towns ran out of coffins and people could not be buried fast enough.

It was only when the threat of the flu could not be denied that procedures to try and curb the infection (flatten the curve in today’s terminology) were put into place.  Each state and city had their own instructions but they included a mix of the following procedures.

  1. Wear masks
  2. Don’t shake hands
  3. Stay in doors
  4. Closed schools and theaters and limited public gatherings

There were places that instituted these practices early, such as San Francisco, St. Louis, Milwaukee and Kansas City.  These early adopters had 30% to 50% lower disease and mortality rates than cities that enacted fewer restrictions and/or started their restrictions later.  It should be noted that other than schools, theaters, churches and bars there were few other businesses that were forced to shutdown.  Compliance to these restrictions was highly variable from city to city and enforcement was often a problem.

1917 vs 2020.

The world is a difference place now that it was in 1917.  In 1917 the world was at war and millions of people were being moved to fight or flee from the war in Europe.  The conditions of the war overcrowding, dampness, malnutrition provided ample opportunity for infections to spread.  Millions of people were transported into and out of the US that were infected with the Spanish flu.  Especially, after the war infected soldiers returned to their homes all over the US.  The movement of millions of people in a short period of time is exactly the opposite of a travel ban.

The political atmosphere was generally not to tell the truth regarding the disease and to downplay it’s seriousness.  This lack of candor was accompanied by organizing large gatherings of people despite knowing that there was a serious infectious disease in their presence.  It was not easy for the public get accurate information about the effects of the Spanish Flu.

There was a shortage of doctors compared today but the shortage was made even worse in the US as a large number of doctors were in the Army and overseas.  There were also fewer hospital beds per capita in 1918.

The 1917 level of medical knowledge and medical technology was very low compared today.  The ability to test for the disease was virtually nonexistent in 1917.

Social distancing and masks appear to have been effective in 1917 and appear to be effective now.  However, the shutdown of nonessential businesses around the world has never been done before.  Given all the other societal and technical differences between 1917 and now, it is not clear how effective a nationwide shutdown of businesses in 1917 would have been with hundreds of thousands of infected people returning home.

Unlike the situation in 1917, there is a lot of information regarding Covid 19 from around the world easily accessible via the internet and television.  Unlike 1917, the statistics of Covid 19 are posted often and the public has direct knowledge of the effect of the disease in their city, county and state.

Quarantines

The most effective efforts had simultaneously closed schools, churches, and theaters, and banned public gatherings along with the use of masks.  There were no large scale shutdowns of other businesses, although some places staggered business hours.  At later stages of the epidemic, they tried to isolate those who had the disease but I can not find many efforts to quarantine (isolate) those who were not infected.

Lessons

Public officials in charge of public health must be honest with the public and give truthful assessment of the disease.

Disease must be recognized and mitigating policies must be put in place to slow the spread of the virus.

You can slow down and reduce infections if you do social distancing and wear masks.

No gatherings of large numbers of people if you can not also social distance and wear masks.

We should be wary of how decisions are made and be aware if a decision is politically driven or public health driven.

There were many societal differences between 1917 and 2020.  The main difference being World War I and the associated movement of people, along with crowded and poor conditions.  The 1917 public was not well informed of the number of infections and number of fatalities caused by the Spanish Flu.

 

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.