On Wednesday March 11, the NBA announced it would be suspending its season due to COVID-19, and other professional sports leagues soon followed suit. Over the past week, concerts, conferences, and other large gatherings were cancelled amid concern for the outbreak to apply a strategy known as “social distancing.” Students from universities across the country are being sent home, children are out of school, and employers are scrambling to develop guidance for employees to work remotely. And yet the reaction of the public is one of polar opposites: either sheer panic or no big deal (how very on-brand for the U.S.).
Social distancing refers to literally creating more distance between individuals by enacting measures that prevent congregate settings. It may seem extreme, take for example this text my sister sent me this week:
As respiratory infections go, COVID-19 and influenza do share many similarities. First, both SARS-CoV-2 and influenza virus are transmitted by respiratory droplets, meaning that close contact with a coughing or sneezing person is the easiest way to get the disease. Second, both viruses cause a spectrum of disease from mild upper respiratory infection (ie. common cold) to life-threatening pneumonia. The mortality rate of influenza is about 0.1% (one person will die for every 1,000 people infected). Early estimates of the mortality rate of COVID-19 are about 2% (two deaths for every 100 infections). Given that we are just beginning to understand the scope of mild infections, this estimate is higher than the true mortality rate, which may turn out to be closer to that of influenza.
While COVID-19 may be more deadly than influenza, the question about extreme measures to enforce social distancing for one infection and not the other is a great one. The answer just happens to be my favorite topic in the world – immunity.
Throughout our lives, we are exposed to influenza viruses from annual vaccinations and natural infections, which help us build immunity. Each exposure induces antibodies that can bind up the virus and killer white blood cells that seek and destroy infection. Sometimes our immune system can completely prevent us from getting sick and other times it makes a flu infection less severe.
In contrast, SARS-CoV-2 is a brand-new virus that humans have never been exposed to. That is, we have no immunity and we are all susceptible to infection.
From a public health perspective, this means that seasonal influenza only infects a fraction of the population while SARS-CoV-2 has the ability to infect us all. That’s not to say that influenza isn’t serious or important. In the U.S., it is estimated that influenza has caused 34 million illnesses with 350,000 hospitalizations and 20,000 deaths this season alone. That’s nothing to scoff at, but because we have no pre-existing immunity to SARS-CoV-2, the potential number of cases is essentially the entire population of Earth — 7.7 billion people. Without minimizing exposure by instituting social distancing practices, SARS-CoV-2 could sweep through the world necessitating billions of hospitalizations, which we are unequipped to handle, and leading to millions of deaths.
If you’ve watched the news lately, you may have seen Dr. Anthony Fauci, Director of the National Institute of Allergy and Infectious Disease at the NIH promoting protective measures to “flatten the curve.” What he means by this is implementing social distancing and advocating for better respiratory hygiene to slow the spread of SARS-CoV-2 and prevent the outbreak from exceeding the capacity that the healthcare system can handle. If hospitals are overwhelmed with COVID-19 patients, we will see poorer outcomes not just for those with COVID-19, but also for others seeking medical attention. For an inside peak at what this looks like in Italy (15,113 cases with 1,016 deaths as of March 13), read this horrifying Twitter thread.
Even with social distancing, many people will still get infected and many people will die of COVID-19 here in the U.S. Case counts will undoubtedly rise in the coming weeks. It’s important to remember that this does not indicate a rapid expansion of disease nor a failure of social distancing, but better detection due to expanded availability of testing reagents. While a certain person sitting in a geometrically shaped office inside a particular color house will not “like the numbers,” we’ll soon have a better understanding of the situation in the U.S. that will help to inform whether we need to do more to contain it.
As our case counts rise and we prioritize these next steps, we should learn from countries that have handled their outbreaks. Take for example China, which despite reaching 80,000 cases last week, has slowed the spread of COVID-19 considerably. Only 11 new cases were reported on March 13 compared to 1,820 reported on February 13. While you might think that mass city quarantines and travel restrictions throughout China made the biggest difference, it might actually turn out to be their local responses that had the most impact. According to a recent episode of the New York Times Daily podcast, a mass screening strategy of so-called “fever clinics” across China allowed healthcare workers to effectively triage and separate people based on their likelihood of having COVID-19.
The first step at a fever clinic was for healthcare workers wearing full protective suits to evaluate fever, symptoms, and exposure history in essentially everyone. This first layer of screening typically occurred outside hospitals such as in a parking lot or other separate area. People without fever, symptoms, or risk of exposure were allowed to go home. People with any of these features got shuttled to another designated space such as make-shift hospitals or gymnasiums to get a blood test and an influenza test. This second layer of testing grouped individuals into three buckets: patients with flu, patients with a likely bacterial infection, and patients who are suspected to have COVID-19. Patients in whom COVID-19 was still suspected then got a CT scan to look for damage in the lungs and were further physically separated before getting a COVID-19 test.
These fever clinics, while aggressive, contributed greatly to 1) identifying individuals at high probability for COVID-19 and 2) separating individuals who could transmit disease (COVID-19 and other infectious diseases), but definitely raised some ethical questions. Most notably being that every person (no matter their age or relationship to others) was put through the screening system individually. That meant that if a parent and child fell into disparate groups, that child was separated from their parent.
Similar, but less strict screening protocols could make a huge difference here in the U.S, provided we have enough tests to undertake the process. One of the biggest factors in our delayed detection and, therefore, response has been difficulty developing enough tests for the virus. Our traditional system of patients seeking testing from their healthcare provider is likely to be ineffective as a public health screening method. I’m sure that people who don’t need it are already asking about COVID-19 testing at the expense of tests for those who do.
Let’s all give our healthcare workers a fighting chance by doing what we can to flatten the curve. Stay out of congregate settings and stay at home as much as possible. Does this mean you can’t leave your house? Not necessarily, but do so considering all the risks. Ask yourself how many people will be where you’re going and how far apart each person can reasonably be. If it’s less than 6 feet, reconsider your attendance. Think about what you’ll have to touch on your way there or once your present (the more surfaces, the more careful I’d be). Factor in your own risk profile. Someone at an advanced age or with an underlying condition is at even greater risk.
If you are feeling unwell, leave your house only at the advice of your healthcare provider and follow their instructions for getting to the healthcare facility.
We will all undoubtedly encounter a situation in which we don’t have a choice and may find ourselves in an uncomfortable circumstance at the grocery store, on a bus, or at the doctors office. Remember that we are all in this together. The person next to you is just as unsure about you as you are of them. Be kind.
So, are we doing enough to stop COVID-19? Only time will tell. The more successful these measures are, the more overblown they’ll seem. If effective, some will say that it was all an overreaction. I’d prefer that outcome than the one where it’s clear we didn’t do enough.
More resources:
SARS-CoV-2 (COVID-19) is spreading, but there is good news
A Mysterious Case of COVID-19 Has Appeared in the U.S. What Do We Do Now?
Five Myths About Coronavirus Debunked
CDC Coronavirus Disease 2019 (COVID-19)
STAT News – Coronavirus