Remember last week’s “cautious optimism” over plateauing COVID-19 infections and critical care demands? Well, it appears to have taken a hit this week. Reviewing the week’s developments, it seems that cautious optimism has morphed into something more like tepid realism as the virus becomes more of a political and philosophical battle, rather than a question to be answered by science and medicine. You’re probably thinking, it’s the economy, stupid. And you’re absolutely right. As PPP funds ran dry and frustrated and frightened Americans deal with unemployment, many let it be known that they have had enough of social distancing. Armed citizens took to the steps of Michigan’s state house. This haunting image came to us out of Ohio. Protestors demonstrated in Austin. All while President Trump appeared to encourage the activism on Twitter. As any physician will tell you, unfortunately, COVID-19 doesn’t care about who you voted for, your interpretation of the constitution, whether it was manufactured in a lab or emerged naturally, or if you watched Tiger King. All it cares about is highjacking your genetic material to make more of itself. What you missed from the weekend The New York Times interviewed health experts as to what the next couple of years might look like in the U.S. Many see waves of infections as we ease in and out of social distancing. “Every epidemiological model envisions something like the dance. Each assumes the virus will blossom every time too many hosts emerge and force another lockdown. Then the cycle repeats.” Harvard researchers have said that reopening the U.S. economy hinges on ramping up COVID-19 testing. The New York Times reports that we’re testing about 146,000 people daily. Harvard scientists estimate that number needs to be between 500,000-700,000 if the country is to re-open by mid-May. Governors in hard-hit states have asked the federal government for assistance to expand testing. It looks like contamination at CDC labs may have slowed the initial rollout of testing. A research team is looking at whether dogs can be used to detect COVID-19. Clinical studies of hydroxychloroquine and other malaria drugs are not looking good. Chinese and Brazilian studies showed that the drugs did not help patients recover faster. A French study demonstrated that the drugs didn’t reduce deaths or admissions. Additionally, some participants in the Brazilian study who were in a high-dose study group experienced experienced ventricular tachycardia. The U.S.-Canadian border will remain closed for another 30 days. The daily death toll in Italy is at its lowest since April 12 while the number of new cases appears to have stabilized. Florida re-opened its beaches, and people took the opportunity to soak up some sun. Hopefully they didn’t soak up some aerosolized viral particles in the process. About 100,000 people attended a politician’s funeral in Bangladesh. Looking ahead Here’s what we’re keeping an eye on this week: A possible second peak We have been through this before. We have the benefit of history and experience in how we respond to COVID-19. But it all boils down to whether we choose to use this experience, or ignore it. Meet Howard Markel, M.D., Ph.D. of the University of Michigan Center for the History of Medicine. The University of Michigan says he’s the guy who coined the phrase, “flatten the curve.” As a physician historian, Markel has made a career of studying the history of pandemics. He says that right now, we’re in a position where we could squander any progress we have made containing COVID-19. “In every pandemic, there’s a tug of war. On one end, there are the economic and business interests, and on the other end is the public’s health,” he says. “We know from history that when citizens become restless and protest to their leaders about lifting these sanctions too early, another rise in cases invariably occurs. In some places it was worse than the first peak.” This happened during the 1918 flu pandemic. Take a look at these graphs, organized by National Geographic. You’ll notice a trend. Many feature a pronounced, second hump that follows the initial peak in weekly deaths per 100,000 cases. This is the second peak. In some cases, like in Denver and St. Louis, it’s bigger than the initial spike. Markel published a comprehensive study in 2007 on the efficacy of non-pharmaceutical interventions during the 1918 pandemic, such as shutting down schools and restricting public gatherings. Markel and the team of researchers concluded that timing these types of interventions was critical — and so is keeping them in place for an appropriate amount of time. Cities that backed off too soon faced large second waves. “These second peaks frequently followed the sequential activation, deactivation, and reactivation of nonpharmaceutical interventions, highlighting the transient protective nature of nonpharmaceutical interventions and the need for a sustained response. … Such dual-peaked cities are of particular interest because of the specificity and temporal associations between excess mortality and the triggers of activation and deactivation of nonpharmaceutical interventions and the implications for a causal relationship. Among the 43 cities, we found no example of a city that had a second peak of influenza while the first set of nonpharmaceutical interventions were still in effect, suggesting that each city with a bimodal pattern served as its own control.” The takeaway: What’s the saying about history repeating itself? We didn’t pay attention in history class. Testing, testing, 1, 2, 500,000 So, what’s with that 500,000-700,000 daily tests figure? According to Ashish Jha, the director of the Harvard Global Health Institute, that’s the number we need to hit in order to open the economy, and keep it open. The simple explanation, according to Jha, is that more testing means we can be more certain about who doesn’t have the virus. These people can return to work without risk of infecting others or becoming infected themselves while those who are sick remain in isolation. But why does the testing figure need to be triple its current total? Jha explains that we’re trying to reach a tolerable amount of uncertainty over who is and isn’t infected. “In every way we can think about this, 500,000 tests per day is probably too low,” Jha writes. “We are likely substantially under-counting deaths and, therefore, the number of cases is likely higher. If, on the other hand, a case fatality rate of 1% is too high, that means there is a larger pool of asymptomatic individuals who are possible carriers of the coronavirus. Even if the (Case Fatality Rate) is 0.8%, that adds a lot more cases. A 10% test positivity rate would miss a lot of infected folks – as would the approach to trace and test on average only 10 contacts per positive.” The 10% positivity rate is what the World Health Organization recommends to “ensure most cases are being identified.” Jha argues that the way forward is to use a “Test, Trace, and Isolate Individuals with Flu-Like Symptoms Approach.” This involves: Beginning with the 45,000 confirmed new COVID-19 cases on May 1. We then test all people with influenza-like symptoms. There were about 85,000 of these people as of May 1. Test contacts with positive cases. Between 10. That means we would need about 450,000 additional tests. Add the 85K tests needed for people with flu-like symptoms to the additional 450K needed for contact tracing, and you arrive at a total test need of about about 535,000. Source
