Flatten The Curve

OK... What Now? by Nancy Ohanian

In Paris, the Louvre and the Eiffel Tower are now closed to the public. In Orange County, the Richard Nixon Library in Yorba Linda, where elderly people line up to spit or piss on his grave, has announced they will be closing down for the duration of the pandemic.

My most recent favorite restaurant in L.A. is Avra, a seafood restaurant with a distinctly Greek flair. But it is so expensive that I tend not to go there unless someone on a corporate credit card invites me. And this week someone did, someone I liked and was looking forward to get together with as well. But no matter how many times I told myself that the tables are pretty far from each other-- especially in the back room where I always sit-- it's still a restaurant and I'm not eating in restaurants any for the duration. So I called my friend and begged off. I made a delicious 5-bean soup instead-- nutritious, easy and totally yummy.

Starting dinner-time yesterday, according to New York Eater, Cuomo and de Blasio ordered that "all venues in the state seating 500 people or less will need to reduce capacity by 50 percent-- including restaurants and bars." That is something every state should do... if the venue has a capacity of 100 or less. What if a restaurant holds 400 people; why should they be allowed to serve 200 when a smaller restaurant serving 80 people is forced to serve just 40? Better though, a step in the right direction: "Events for more than 500 people have been completely banned." All Broadway shows are also shutting down.

Businesses in New York state that refuse to comply, will be shut down entirely.

I was happy to see Los Angeles and San Diego-- under pressure from unions and despite a lackadaisical attitude from California's corporate governor-- order the closure of all public schools in the two cities. The closure is supposedly for 2 weeks, but there is no indication that two weeks from now could be far worse.

So far 7 states (+DC) have also announced public school closures: West Virginia, Virginia, Maryland, New Mexico, Oregon, Michigan and Ohio. Other states, like Washington, have partial shutdowns, and Kentucky has a recommendation to school districts to shut down. The mainstream media-- including The Post insinuating children are immune to COVID-19, which is a claim derived from faulty Chinese data. Children are contracting the disease and are dying, though not at the rate as the elderly.

Ohio’s governor said Thursday that all of the state’s public and private schools would close for three weeks or more... “We are going to do what we have to do. We are in a crisis,” Ohio Gov. Mike DeWine (R) said. Closures in Ohio will begin at the close of classes Monday and run through at least April 3, DeWine said. “It may be a lot longer.” ... The U.S. Education Department responded to the growing number of closures with new guidance, easing some rules around testing requirements and clarifying responsibility for educating students with disabilities via remote instruction. Ohio was the first state to make the move, in part because the Director of the Ohio Department of Health, Amy Acton, said she believes roughly 1% of the state's population is believed to already be carrying the virus. That's a very conservative estimate but it equates to over 100,000 people.

Few Republicans are as conscientious about the pandemic as the Ohioans. Tom Dadey is a well-known facts-free Trump toady in Syracuse, New York, where he is chairman of the Onondaga County Republican Party. His twitter feed hasn't caught up with Trump's national emergency yet and as of Friday he was still pretending that the pandemic is no big deal.

A friend sent me a read out from a March 10th UCSF panel on COVID-19 hosted by Dr. Jordan Shlain that's worth reading, especially if you've missed the Chris Martenson video-blogs we've been posting everyday for about a month. The panelists were Joe DeRisi, UCSF’s top infectious disease researcher and co-inventor of the chip used in SARS epidemic, Emily Crawford, COVID task force director, Cristina Tato, Rapid Response Director and immunologist, Patrick Ayescue, leading outbreak response and surveillance epidemiologist, and Chaz Langelier, UCSF Infectious Disease doctor.

Top takeaways

At this point, we are past containment. Containment is basically futile. Our containment efforts won’t reduce the number who get infected in the US.

Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak. In other words, the goal of containment is to "flatten the curve," to lower the peak of the surge of demand that will hit healthcare providers. And to buy time, in hopes a drug can be developed.

How many in the community already have the virus? No one knows.

We are moving from containment to care.

We in the US are currently where at where Italy was a week ago. We see nothing to say we will be substantially different.

40-70% of the US population will be infected over the next 12-18 months. After that level you can start to get herd immunity. Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.

[We used their numbers to work out a guesstimate of deaths-- indicating about 1.5 million Americans may die. The panelists did not disagree with our estimate. This compares to seasonal flu’s average of 50K Americans per year. Assume 50% of US population, that’s 160M people infected. With 1% mortality rate that's 1.6M Americans die over the next 12-18 months.]

The fatality rate is in the range of 10X flu.

This assumes no drug is found effective and made available.

The death rate varies hugely by age. Over age 80 the mortality rate could be 10-15%

Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did.

I can only tell you two things definitively. Definitively it’s going to get worse before it gets better. And we'll be dealing with this for the next year at least. Our lives are going to look different for the next year.

What should we do now? What are you doing for your family?

Appears one can be infectious before being symptomatic. We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms. We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).

How long does the virus last?

On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this.

The virus is very susceptible to common anti-bacterial cleaning agents: bleach, hydrogen peroxide, alcohol-based.

Avoid concerts, movies, crowded places.

We have cancelled business travel.

Do the basic hygiene, eg hand washing and avoiding touching face.

Stockpile your critical prescription medications. Many pharma supply chains run through China. Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.

Pneumonia shot might be helpful. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.

Get a flu shot next fall. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.

We would say “Anyone over 60 stay at home unless it’s critical.” CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.

We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes. Then are not letting them out of the house. The other members of the family are washing hands the moment they come in.

Three routes of infection:

• Hand to mouth / face
• Aerosol transmission
• Fecal oral route

What if someone is sick?

If someone gets sick, have them stay home and socially isolate. There is very little you can do at a hospital that you couldn’t do at home. Most cases are mild. But if they are old or have lung or cardio-vascular problems, read on.

If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.

There is no accepted treatment for COVID-19. The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease. ie to prevent sepsis.

If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use" of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China. Need to find a doc there in order to ask to enroll. Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19. If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.

Why is the fatality rate much higher for older adults?

• Your immune system declines past age 50
• Fatality rate tracks closely with “co-morbidity”, ie the presence of other conditions that compromise the patient’s hearth, especially respiratory or cardio-vascular illness. These conditions are higher in older adults.
• Risk of pneumonia is higher in older adults.

What about testing to know if someone has COVID-19?

Bottom line, there is not enough testing capacity to be broadly useful. Here’s why.

Currently, there is no way to determine what a person has other than a PCR test. No other test can yet distinguish "COVID-19 from flu or from the other dozen respiratory bugs that are circulating.”

A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA. However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.

The PCR test requires kits with reagents and requires clinical labs to process the kits.

While the kits are becoming available, the lab capacity is not growing.

The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day. For the nation.

Expanding processing capacity takes “time, space, and equipment.” And certification. ie it won’t happen soon.

UCSF and UC Berkeley have donated their research labs to process kits. But each has capacity to process only 20-40 kits per day. And are not clinically certified.

Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.

How well is society preparing for the impact?

Local hospitals are adding capacity as we speak. UCSF’s Parnassus campus has erected “triage tents” in a parking lot. They have converted a ward to “negative pressure” which is needed to contain the virus. They are considering re-opening the shuttered Mt Zion facility.

If COVID-19 affected children then we would be seeing mass departures of families from cities. But thankfully now we know that kids are not affected.

School closures are one the biggest societal impacts. We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects. If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.

Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis. They do not have the capacity to sustain for outbreaks that last for months. Other solutions will have to be found.

What will we do to handle behavior changes that can last for months?

Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.

Kids home due to school closures

...Where do you find reliable news?

The John Hopkins Center for Health Security site. Which posts daily updates. The site says you can sign up to receive a daily newsletter on COVID-19 by email.

The New York Times is good on scientific accuracy.

Observations on China

Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.

While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.

Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand. Wuhan built 2 additional hospitals in 2 weeks. Even so, most patients were sent to gymnasiums to sleep on cots.

Early on no one had info on COVID-19. So China reacted in a way unique modern history, except in wartime.

Every few years there seems another: SARS, Ebola, MERS, H1N1, COVID-19. Growing strains of antibiotic resistant bacteria. Are we in the twilight of a century of medicine’s great triumph over infectious disease?

"We’ve been in a back and forth battle against viruses for a million years."

But it would sure help if every country would shut down their wet markets.

As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa. See article on Wired magazine on sequencing of virus from Cambodia.

The Dos and Don’ts of ‘Social Distancing’ was carried by The Atlantic yesterday-- "Experts weigh in on whether you should cancel your dates, dinner parties, and gym sessions," by Kaitlyn Tiffany.

Because of so much bad information floating around-- some of it from imbeciles like Trump, Fox, congressional Republicans and Dr. Drew and some from usually trusted sources-- she took questions to a series of public-health experts-- Carolyn Cannuscio, the director of research at the Center for Public Health Initiatives at the University of Pennsylvania, Crystal Watson, a senior scholar at the Johns Hopkins Center for Health Security, and Albert Ko, the chair of the epidemiology department at the Yale School of Public Health. "If you’re confused about what to do right now," she wrote, "you’re not alone-- even these experts occasionally disagreed on the answers to my questions... There is a general consensus that while young and healthy people who are at lower risk for personally suffering severe illness from the coronavirus don’t have to be locking themselves in their homes for the next month, they do need to dramatically alter their daily lives, starting now."

If I’m Symptom-Free:

Should I Be Avoiding Bars And Restaurants?

Cannuscio: People should avoid gathering in public places. People should be at home as much as possible. The measures that have worked to get transmission under control or at least to bend the curve, in China and South Korea, have been extreme measures to increase social distancing.

Watson: It depends on local context. If we’re in a situation where the disease has been shown to be spreading widely, I think people will start to want to stay home and not go out into crowded settings.

Albert Ko: If you go to a crowded bar where you’re up one against another, that’s a lot different from going to a bar where you’re spread out. The CDC recommendations are to keep six to 10 feet away from other people. Bottom line, there’s no absolute indication not to go to bars and restaurants, but in practicing good public health-- which is kind of a responsibility for everybody in the country-- really think about how we can decrease those close contacts.

Can I have a small group of friends over to my house for a dinner party or a board-game night?

Watson: I think small gatherings are probably okay as long as nobody has symptoms, respiratory symptoms. As soon as someone seems sick, you should probably not get together.

Ko: We’re in a gray zone now. The public-health imperative is to create social distance; that’s the only way we’re going to stop this. Think about having those get-togethers but practicing good public health: not sitting very close, trying to keep distance. Wash your hands; avoid touching your face. There are places on the board game that people are constantly touching-- routinely disinfect [those, as well as] doorknobs, the bathroom faucets, those types of things. There’s no absolute rule about what works, but what we do know is that decreasing the size of those gatherings, increasing the distance, practicing good hygiene will go a long way.

Cannuscio: I would recommend that people minimize social contact, and that means limiting all social engagements. That includes intimate gatherings among friends. I think the exception is if two households are in strict agreement that they are also going to reduce all outside contact and then those two households socialize together, to support one another. I can see social and mental-health advantages to that kind of approach.

Should I stop dating?

Ko: Dating is usually one person and another person. What we’re really worried about in terms of public health are these large gatherings where you have people crowded together, and you can have what we call super-spreading events. The risk of those goes up exponentially the larger the size of the gathering. Dating is at the other end. I think you can still date.

Watson: I think dating is okay, if you believe with reasonable confidence that you’re both well. I think we’re humans and we need human interaction; I think that’s important for our sanity. It’s important to focus on [avoiding] large crowds and indoor activities where you have lots of people touching the same surfaces.

Cannuscio: It is a time to be very cautious about initiating contact with new people. This seems like a great time to get creative with your text messages. [Or] take it to FaceTime or a phone call.

Can I go to the gym?

Ko: If you do go to the gym, again, maintain distances. Disinfect places in the gym people are always touching. Wash your hands regularly. Much of the transmission is person to person with people coughing, sneezing, or touching their nose and mouth and touching somebody else. You can get transmission on surfaces; that’s probably a little bit lower-risk, but we still should disinfect surfaces that we touch.

Cannuscio: If you’re going to go to the gym, try to go at a time when there are very few people there and definitely wipe down the equipment. However, as the weather warms in many parts of the United States, I would instead recommend that people go outside for walks or runs or bike rides in areas where there are not other people. This is really about depriving the virus the opportunity to move from one person to another.

Should I be worried about going to the grocery store?

Cannuscio: I would say try to shop at times when there are very few other shoppers there. That [could mean] going first thing in the morning when the store opens, or late at night. I think many people will rely on delivery, and that’s just the nature of our lives right now. For delivery workers, I would say, leave the food on the doorstep and ring the bell, rather than interacting face-to-face with the person who’s ordered the food.

Should I take public transportation?

Cannuscio: First of all, people who have the opportunity or the option of working at home should absolutely use that option right now. For people who have essential functions and have to be at work, if they have any flexibility in their schedules they should try to ride at non-peak hours. On subways or buses, people should try to stand as far away from other people as possible. I think it’s important for planners to think about, for example, putting more buses on the most heavily traveled routes, to maybe thin out the crowds on those buses. In cities where it’s possible to walk, that would be a better option.

For people who can afford to use ride-sharing services, you’re limiting the number of people you’re in contact with as the rider, so to me that seems like a reasonable step to take. Of course, I worry about all those drivers who have people in and out of their cars all day long.

And of course, everyone should be using good hand hygiene and respiratory etiquette. If you have to cough, cough into your elbow. And I can’t believe I have to say this, but I’ve been in public places where people have been spitting, in parks or on the sidewalk. I would ask people not to spit!

Watson: It’s hard to say “Don’t take public transit,” because a lot of people rely on it to get to work. If you don’t have to and you can drive, it’s probably a good idea. It will help other people who have to take public transit for their livelihoods to do so and do so more safely.

Should my family be canceling events like birthday parties AND weddings?

Watson: It’s hard to ask everyone if they’re feeling sick and harder to know what their exposures have been. I would take a look at who is invited to the party. Are there people who are very vulnerable? Older people, people who have underlying health conditions, pregnant women? If that’s the case, I would err on the side of caution. I don’t want to tell somebody to cancel their wedding. That would be terrible. But I think you have to look at the situation, maybe ask guests who are feeling ill not to come. If it’s being held in a community where there’s widespread disease, then it might be worth [reconsidering the event].

Ko: If those events can be postponed, I think that’s certainly productive. If a wedding can’t be postponed, there are things you can do. Hold it in an open space, where people are spread apart. You have to be really careful about exposures and really practice social distancing from the elderly.

Cannuscio: One of the best ways we can show love to the people we care about is to step back and to stay away. In many cases that takes courage, and it takes speaking out over these social norms that dictate that we should be polite and we should be together and we should celebrate and gather. Really seriously consider whether now is a joyful time to gather family members for a wedding celebration.

Should I stop visiting elderly relatives?

Watson: I think we should start limiting visitation to people who are in assisted-living facilities and nursing homes. I know that’s really tough, and maybe setting things up so you can visit them virtually is a good idea. [That way], they can see you and say hello, [without putting] them at extra risk.

Cannuscio: I think if we are fortunate enough to live near our elders and we get into the mode of seriously isolating our own families, then one person should be designated to go and visit. If we’re not in a situation where we can truly limit our own social contact, then we will be putting that elder at risk by going to visit.

Should I be canceling haircuts and other nonessential appointments?

Watson: Those are more one-on-one interactions. I think there’s a lower likelihood that exposure is going to occur that way. I don’t think that’s a big concern.

Cannuscio: I would say hold off on your haircut and then when you go back, when it’s clear that we have vanquished this foe, everybody please give your hairdresser extra, extra tips. I hope that policies will be put into place to protect the paychecks of people who will suffer during this period.

Should I avoid communal spaces in my apartment building?

Cannuscio: Try to schedule your use of those common spaces so you’re going at times when other people aren’t around. If you know there are not a lot of people in the laundry room or mailroom at 6 a.m., go at 6 a.m. People will be inconvenienced, but it’s important to try to spread ourselves out.

Should I limit physical interaction with my partner, or other people I live with?

Ko: That’s really hard to do. Again, what we’re really worried about is large gatherings. In the home, close contact is almost inevitable.

Cannuscio: I would say if you’re in a steady, monogamous relationship and you and that other person are limiting your social contacts, then be as intimate as you want to be.

Watson: If you get sick, try to maintain some distance. Otherwise, households should go about their normal business.

If I Get Symptoms or Am Exposed to Someone Who’s Sick:

If I am waiting out a 14-day quarantine, can I have visitors as long as they stand far away from me?

Cannuscio: No, quarantine means “stay away from other people.” You shouldn’t have visitors.

Ko: Under quarantine, people really shouldn’t enter the home or be in the same physical space.


Can I walk around outside at all when I’m under quarantine?

Cannuscio: For people who live in areas that are not densely populated, walking around in their yard is probably safe. The idea is that they should not come into contact with any other people. They need to be strict about it. We are not going to defeat this and halt transmission if people loosely interpret what it means to self-quarantine or self-isolate.