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STAT has a good summary of predictions
May. 3rd, 2020 12:45 pmhttps://www.statnews.com/2020/05/01/three-potential-futures-for-covid-19/
The three scenarios are: lots of future waves, localized measures to suppress them because all are half or less the size of the current one, 1918 Pandemic style monster wave in the fall, and piddling ongoing transmission thereafter, and finally, lots of future waves of roughly the size of the current one.
There are descriptions of why each one might happen, and implications for the health care system, people’s behavior, etc.
I am going to take these out of order.
A lot of people are pretty fascinated by the analogy to the 1918 flu pandemic. Some people are actually pointing out useful things like, places that did social distancing had fewer deaths than places that did not. There is a lot less attention being paid to aspects of that pandemic that seem very relevant: cities were a lot more densely packed in their cores THEN than they are NOW. And we had mobilization of the entire country (countries), including virtually every doctor was part of the war effort, and thus subject to national defense priorities like, do not let the enemy find out that we have epidemic disease, so, do not let anyone publish information about the epidemic disease, and, do not let doctors shut the economy down because we need the economy producing to serve the military effort and do not let doctors shut down rallies and parades related to fund raising for the war effort, etc.
It is also worth noting that there are variable understandings of the causes of mortality in the 1918 flu pandemic. We did not have antibiotics in that time frame, so a lot of deaths THEN were due to what now would be manageable things like secondary bacterial pneumonia infections. While salicylic acid had been a part of the human arsenal for dealing with pain and illness since before we wrote shit down, aspirin was a relatively new thing, and it reduced the major side effect of salicylic acid (damage to the stomach) to a point where people could tolerate way, way, way more salicylic acid. The doses recommended by the surgeon general — and remember, this was in a mobilization of the entire country that put virtually every doctor in a pseudo if not actual militarily subordinate relation to the surgeon general — started at 8 grams a day and went up from there. We know that will kill people and we do not do that now. A lot of people receiving these doses were young people (even children), and it would be decades for Dr. Reyes finally convinced people that giving aspirin at all to young people (especially children) was a terrible idea, even after we had finally worked out the salicylic toxicity problem. Some important fraction of mortality in the 1918 flu pandemic can be attributed to crowding (see a bit more about that below); another important fraction can be attributed to secondary bacterial infection; a third important fraction can be attributed to misuse of aspirin.
We do not yet know what comparable mistakes we are making. Rumors have made the rounds suggesting that one OTC fever reducer or another might be beneficial or harmful. More importantly, attempts to deploy an anti-malarial with a somewhat terrifying and well-known set of harmful side effects, risk repeating some of the errors of the 1918 pandemic. Researchers are diligently looking for possible interactions between known drugs and this novel coronavirus:
https://www.nature.com/articles/s41586-020-2286-9
One of the things they found was that dextromethorphan might be causing trouble. That is a bit worrisome; how many people with a dry cough took dextromethorphan and inadvertently made a minor case of coronavirus a whole lot worse?
There are LOTS of drugs involved in intubating someone to put them on a ventilator; we know some of those can damage kidneys, or cause allergic reactions. We also know that a lot of the people we are intubating are dying rather than recovering — far more than just “most”. What will future analysis suggest, looking back? If we had intubated fewer, would more have survived? Would those more just have been the hospital workers who did not die from exposure at high levels to the virus? Or might even some of those intubated have made it with more a hospice-style approach?
Until The Great War, every major military effort stumbled over diarrheal illness that limited their capacity to wage war. The Great War was the first time they completely controlled that vector. Prior to that, they had been forced to do some amount of distancing to thwart the spread of diarrheal illness. But with diarrheal illness under control, they could really pack people in; they thus found the respiratory crowding limit. This was widely documented both in training camps and staging camps and at the front lines. Doctors measured and calculated the needed distance to get various rates of disease spread and they shared that information with the command chain. And then the command chain did stuff the way they wanted to anyway, and they were not focused on disease spread until the spread of disease shut the entire war down. There are clear and direct parallels with some corporate office strategies in the years leading up to this disease outbreak: cubicle size was shrinking, physical dividers being eliminated, people were required to hot swap in spaces with a lot of touch contact (phones). We knew this was risky; we did it anyway.
I do not see any element of our society engaging in anything like the persistent crowding of The Great War currently (the command kept sending hordes of soldiers into camps full of the already ill), thus, it is difficult for me to imagine spread of the sort that crowding attributable to the war effort caused then, happening today. Option Two seems pretty fucking unlikely to me.
Option 1, then!
The general idea — many waves, for quite a while, but all smaller than this initial one — is plausible to me. And the response — in general, if not in specific — is also plausible to me. We know a lot of people have had versions of this thing so mild that they did not realize they had it (this happened with MERS, also, as was discovered during burden of disease sampling in Saudi Arabia). I find it difficult to believe that once many people have had it, and have antibodies showing that they have had it, that those people will be particularly reluctant to go to concerts (or, say, DisneyLand). But I absolutely believe that we are going to be seeing more telecommuting, telehealth, etc., and hopefully more support in general to encourage people to stay home when they are ill.
A lot of option one (and three, for that matter) involves vagaries associated with testing:
“There will likely be regional variation due to factors including random outbreaks, the bad luck of having super-spreaders, and too little testing and contact tracing to extinguish new outbreaks before they explode.”
There are several problems here. First, I am not sure random is a meaningful qualifier to apply here. Second, I am even less convinced that there is much to do with luck and superspreaders. So let us focus in on the too little testing ... to extinguish new outbreaks before they explode.
Every day that goes by, I become more convinced that we need to quit focusing on testing individuals, and start exploring WBE and any other available strategies that instead collect data from groups that can then be refined with individual testing. Wastewater based epidemiology surveils what is shed into ... wastewater. If you have something that sheds when you pee or poop, WBE can spot it. Testing just before treatment lets you test the entire catchment to see if any is present (and baseline and monitoring can tell you when it is ramping up or down); backtracking along main trunks can localize the outbreak. Individualized testing can then identify who needs to isolate until they quit producing, and if we are very, very clever, and have those people pee and poop into collection separate from the main system, we can see immediately if we got all of the people or should keep looking (where immediately = however long it takes for the sewage to travel from the most distant WC to the treatment plant, which I am betting is not very long).
It may ultimately be worth it to instrument an entire system to make this easier; in the meantime, we can put something temporary together to collect from various trunks and so forth.
The same approach addresses Scenario 3:
“Local outbreaks occur, worse in some places than others due to, among things, different capacity to conduct widespread, regular testing and contact-tracing.”
Honestly, if India can use WBE to keep polio under control, I am pretty sure there is no place in our country we cannot do the same for coronavirus (or other future infectious agents, so long as they are shed into wastewater). I suppose neighborhoods full of septic systems might have difficulties, but they are usually not very dense (or neighbor on places with sewer systems).
Finally, I want to address the fatigue issue:
“Society must referee what Leung calls “a three-way tug of war” among a trio of competing needs: to keep cases and deaths low, to preserve jobs and economic activity, and to preserve people’s emotional well-being. “It’s a battle between what we need to do for public health and what we need to do for the economy and for social and emotional well-being,” he said. If the public health part of the tug-of-war weakens, then the waves will keep on coming through the end of 2022.”
It is entirely too tempting to think of the types of interventions we have adopted (and there are a variety, depending on where and when you are looking!), and shine a moral light on how well those interventions were observed. What really needs to happen is a better understanding of what is actually working. We need to do what is actually working. And we need to stop doing what is not working. Anything that damages our economy and saps our mental and social and emotional health and our cohesion as a community AND DOES NOTHING TO STOP THE SPREAD OF THIS OR ANY OTHER DISEASE is a restriction we need to stop. Just because we felt virtuous following that rule, and because it felt good to land hard on people who did not does not in any way make the rule that does not work any more worth keeping around.
Time and careful attention to detail is what will help us understand what is working and what is not working.
I do not pretend to have any great insight into what works and what does not. There are some pretty obvious insights, tho!
(1) If a bunch of people who do not have the disease hang out together, share food and drink, go for a jog, sing, etc. none of that will cause the disease to spread. The point of testing is to ease up on the people who are all well anyway.
(2) More virus is worse than less virus. That is why being closer to someone with the virus is worse than further, and why health care professionals tend to get such bad cases. It is why being indoors with someone with the virus is worse than being outdoors with the virus.
(3) Some populations get way sicker with this thing than other populations.
The phased reopenings reflect these observations. The variation in strategies will give us insight over time into what degree and what kind of interventions should be adopted for future outbreaks to minimize negative impact and maximize benefit.
Good policies make good politics. I do not think that effective interventions to save lives (and keep our health care system going) will result in fatigue. I do think that interventions which are not obviously effective (and which analysis and communication of the benefits is not done to explain the effectiveness) will result in resistance.
And the easiest prediction of all: some people will complain vociferously, whatever is chosen.
The three scenarios are: lots of future waves, localized measures to suppress them because all are half or less the size of the current one, 1918 Pandemic style monster wave in the fall, and piddling ongoing transmission thereafter, and finally, lots of future waves of roughly the size of the current one.
There are descriptions of why each one might happen, and implications for the health care system, people’s behavior, etc.
I am going to take these out of order.
A lot of people are pretty fascinated by the analogy to the 1918 flu pandemic. Some people are actually pointing out useful things like, places that did social distancing had fewer deaths than places that did not. There is a lot less attention being paid to aspects of that pandemic that seem very relevant: cities were a lot more densely packed in their cores THEN than they are NOW. And we had mobilization of the entire country (countries), including virtually every doctor was part of the war effort, and thus subject to national defense priorities like, do not let the enemy find out that we have epidemic disease, so, do not let anyone publish information about the epidemic disease, and, do not let doctors shut the economy down because we need the economy producing to serve the military effort and do not let doctors shut down rallies and parades related to fund raising for the war effort, etc.
It is also worth noting that there are variable understandings of the causes of mortality in the 1918 flu pandemic. We did not have antibiotics in that time frame, so a lot of deaths THEN were due to what now would be manageable things like secondary bacterial pneumonia infections. While salicylic acid had been a part of the human arsenal for dealing with pain and illness since before we wrote shit down, aspirin was a relatively new thing, and it reduced the major side effect of salicylic acid (damage to the stomach) to a point where people could tolerate way, way, way more salicylic acid. The doses recommended by the surgeon general — and remember, this was in a mobilization of the entire country that put virtually every doctor in a pseudo if not actual militarily subordinate relation to the surgeon general — started at 8 grams a day and went up from there. We know that will kill people and we do not do that now. A lot of people receiving these doses were young people (even children), and it would be decades for Dr. Reyes finally convinced people that giving aspirin at all to young people (especially children) was a terrible idea, even after we had finally worked out the salicylic toxicity problem. Some important fraction of mortality in the 1918 flu pandemic can be attributed to crowding (see a bit more about that below); another important fraction can be attributed to secondary bacterial infection; a third important fraction can be attributed to misuse of aspirin.
We do not yet know what comparable mistakes we are making. Rumors have made the rounds suggesting that one OTC fever reducer or another might be beneficial or harmful. More importantly, attempts to deploy an anti-malarial with a somewhat terrifying and well-known set of harmful side effects, risk repeating some of the errors of the 1918 pandemic. Researchers are diligently looking for possible interactions between known drugs and this novel coronavirus:
https://www.nature.com/articles/s41586-020-2286-9
One of the things they found was that dextromethorphan might be causing trouble. That is a bit worrisome; how many people with a dry cough took dextromethorphan and inadvertently made a minor case of coronavirus a whole lot worse?
There are LOTS of drugs involved in intubating someone to put them on a ventilator; we know some of those can damage kidneys, or cause allergic reactions. We also know that a lot of the people we are intubating are dying rather than recovering — far more than just “most”. What will future analysis suggest, looking back? If we had intubated fewer, would more have survived? Would those more just have been the hospital workers who did not die from exposure at high levels to the virus? Or might even some of those intubated have made it with more a hospice-style approach?
Until The Great War, every major military effort stumbled over diarrheal illness that limited their capacity to wage war. The Great War was the first time they completely controlled that vector. Prior to that, they had been forced to do some amount of distancing to thwart the spread of diarrheal illness. But with diarrheal illness under control, they could really pack people in; they thus found the respiratory crowding limit. This was widely documented both in training camps and staging camps and at the front lines. Doctors measured and calculated the needed distance to get various rates of disease spread and they shared that information with the command chain. And then the command chain did stuff the way they wanted to anyway, and they were not focused on disease spread until the spread of disease shut the entire war down. There are clear and direct parallels with some corporate office strategies in the years leading up to this disease outbreak: cubicle size was shrinking, physical dividers being eliminated, people were required to hot swap in spaces with a lot of touch contact (phones). We knew this was risky; we did it anyway.
I do not see any element of our society engaging in anything like the persistent crowding of The Great War currently (the command kept sending hordes of soldiers into camps full of the already ill), thus, it is difficult for me to imagine spread of the sort that crowding attributable to the war effort caused then, happening today. Option Two seems pretty fucking unlikely to me.
Option 1, then!
The general idea — many waves, for quite a while, but all smaller than this initial one — is plausible to me. And the response — in general, if not in specific — is also plausible to me. We know a lot of people have had versions of this thing so mild that they did not realize they had it (this happened with MERS, also, as was discovered during burden of disease sampling in Saudi Arabia). I find it difficult to believe that once many people have had it, and have antibodies showing that they have had it, that those people will be particularly reluctant to go to concerts (or, say, DisneyLand). But I absolutely believe that we are going to be seeing more telecommuting, telehealth, etc., and hopefully more support in general to encourage people to stay home when they are ill.
A lot of option one (and three, for that matter) involves vagaries associated with testing:
“There will likely be regional variation due to factors including random outbreaks, the bad luck of having super-spreaders, and too little testing and contact tracing to extinguish new outbreaks before they explode.”
There are several problems here. First, I am not sure random is a meaningful qualifier to apply here. Second, I am even less convinced that there is much to do with luck and superspreaders. So let us focus in on the too little testing ... to extinguish new outbreaks before they explode.
Every day that goes by, I become more convinced that we need to quit focusing on testing individuals, and start exploring WBE and any other available strategies that instead collect data from groups that can then be refined with individual testing. Wastewater based epidemiology surveils what is shed into ... wastewater. If you have something that sheds when you pee or poop, WBE can spot it. Testing just before treatment lets you test the entire catchment to see if any is present (and baseline and monitoring can tell you when it is ramping up or down); backtracking along main trunks can localize the outbreak. Individualized testing can then identify who needs to isolate until they quit producing, and if we are very, very clever, and have those people pee and poop into collection separate from the main system, we can see immediately if we got all of the people or should keep looking (where immediately = however long it takes for the sewage to travel from the most distant WC to the treatment plant, which I am betting is not very long).
It may ultimately be worth it to instrument an entire system to make this easier; in the meantime, we can put something temporary together to collect from various trunks and so forth.
The same approach addresses Scenario 3:
“Local outbreaks occur, worse in some places than others due to, among things, different capacity to conduct widespread, regular testing and contact-tracing.”
Honestly, if India can use WBE to keep polio under control, I am pretty sure there is no place in our country we cannot do the same for coronavirus (or other future infectious agents, so long as they are shed into wastewater). I suppose neighborhoods full of septic systems might have difficulties, but they are usually not very dense (or neighbor on places with sewer systems).
Finally, I want to address the fatigue issue:
“Society must referee what Leung calls “a three-way tug of war” among a trio of competing needs: to keep cases and deaths low, to preserve jobs and economic activity, and to preserve people’s emotional well-being. “It’s a battle between what we need to do for public health and what we need to do for the economy and for social and emotional well-being,” he said. If the public health part of the tug-of-war weakens, then the waves will keep on coming through the end of 2022.”
It is entirely too tempting to think of the types of interventions we have adopted (and there are a variety, depending on where and when you are looking!), and shine a moral light on how well those interventions were observed. What really needs to happen is a better understanding of what is actually working. We need to do what is actually working. And we need to stop doing what is not working. Anything that damages our economy and saps our mental and social and emotional health and our cohesion as a community AND DOES NOTHING TO STOP THE SPREAD OF THIS OR ANY OTHER DISEASE is a restriction we need to stop. Just because we felt virtuous following that rule, and because it felt good to land hard on people who did not does not in any way make the rule that does not work any more worth keeping around.
Time and careful attention to detail is what will help us understand what is working and what is not working.
I do not pretend to have any great insight into what works and what does not. There are some pretty obvious insights, tho!
(1) If a bunch of people who do not have the disease hang out together, share food and drink, go for a jog, sing, etc. none of that will cause the disease to spread. The point of testing is to ease up on the people who are all well anyway.
(2) More virus is worse than less virus. That is why being closer to someone with the virus is worse than further, and why health care professionals tend to get such bad cases. It is why being indoors with someone with the virus is worse than being outdoors with the virus.
(3) Some populations get way sicker with this thing than other populations.
The phased reopenings reflect these observations. The variation in strategies will give us insight over time into what degree and what kind of interventions should be adopted for future outbreaks to minimize negative impact and maximize benefit.
Good policies make good politics. I do not think that effective interventions to save lives (and keep our health care system going) will result in fatigue. I do think that interventions which are not obviously effective (and which analysis and communication of the benefits is not done to explain the effectiveness) will result in resistance.
And the easiest prediction of all: some people will complain vociferously, whatever is chosen.