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Step Back, Take a Breath, Think About the Big Picture

By November 14, 2020Commentary

That is my advice to myself every day.  Take all the cumulative research and data, distill it down to the important points and analyze in a rational and logical manner what it is telling us.  Apparently to many of our political leaders the message is “PANICCCCCC!!!  RUN AND HIDE IN THE BASEMENT!”  The Governors of New Mexico and Oregon have put a “freeze” on their states, which is a cute way of describing the Osterheimlich Maneuver or extreme lockdown.  The only thing frozen is their brains.  Apparently they have learned nothing from the Spring or Summer and are deep in the acute phase of Coronamonomania.  I am waiting for the IB to cave in and do the same thing and I will again give him a lot of credit if he rightly resists that temptation and again becomes The Governor.

This is a recapitulation of much of the basics that I have presented before.  This strain of coronavirus is clearly more dangerous and lethal than the typical seasonal coronavirus strains, and follows the pattern over the last 20 years of coronavirus strains tending to emerge that are more dangerous.  This version may be more infectious because it has a different, more common cell receptor, it has a stronger receptor binding capacity and it may have an enhanced ability to down-regulate the immune system.  I believe that the evidence strongly suggests it can survive and drift in smaller aerosolized particles in the right conditions and that this ability accounts for the difficulty in suppressing transmission.  At an individual level, upon exposure, actual meaningful infection appears to be dependent on a large variety of factors, including viral dose (the number of virus particles or virions) and the health status of the exposed individual, particularly their immune status.  People appear to be capable of transmitting while asymptomatic or presymptomatic, although such persons may have lower viral loads and other characteristics (e.g., not coughing) that lessen the likelihood that they will actually infect another person.

From an epidemiologic or population perspective, what matters most is understanding these transmission dynamics, understanding population susceptibility and assessing the effectiveness of potential measures that might be taken to control spread.  Obviously, understanding the danger posed by the pathogen is also critical knowledge in determining what mitigation measures, if any, might be appropriate.  CV-19 is an interesting pathogen, the most studied in history, exceeding even the HIV virus.  It is not that lethal, for which we should be grateful and has an incredible severity gradient across age.  For the general working age population without certain serious pre-existing health conditions, like true obesity, it is a threat, but no more so than many other potential harms.  For children and young adults, serious illness is very rare.  For the frail elderly, it is often deadly, although even among this population large percentages of asymptomatic infections can be found.  Primary features from an epidemiologic perspective would include this extreme bifurcation of illness by age, potential front-loading of severe illness with the most vulnerable being affected first, and apparent high transmissibility or infectiousness in some settings.  Another facet of the epidemic that should be very apparent now is a geographical, seasonal pattern that creates a far more hospitable environment for the virus and transmission under certain circumstances.  The Upper Midwest and Rocky Mountain states and Europe appear to be particularly favorable to transmission at this time.  It is also intriguing that much of Asia appears to have more limited transmission, although in some countries, such as China, opaque data makes accurate assessment of spread or prevalence difficult.  While mitigation strategies may be responsible for this difference, I believe it is equally likely that general health status, particularly much lower prevalence of obesity, and greater pre-existing immune response capability are responsible.  It would be extremely helpful to separate the health and biological aspects of the apparent differential spread in Asia from the response ones.

An epidemic slows when the virus finds fewer targets that can be infected.  It does not appear that even at the start of the CV-19 epidemic all persons were equally susceptible to either being infected or being infectious.  This is likely largely due to variation in immune system status, and in particular, there may be significant number of people with either general immune responses to pathogens or specific adaptive immune responses stemming from prior seasonal coronavirus infections.  If so, and a substantial body of research supports this possibility, these persons upon exposure likely clear the virus before becoming infectious.  People who have a CV-19 infection develop a strong and durable adaptive immune response, with very rare exceptions.  This response may be dominated by the T cell arm of adaptive immunity, but strong B cell and antibody responses are also present.  A vaccine would futher facilitate adaptive immunity and slow transmission.

A substantial portion of the US population has likely been infected and/or has reduced susceptibility to infection, particularly in more densely populated areas.  Even in this new case surge, it appears that more densely populated metropolitan areas are seeing slowing slower case growth than areas which likely did not experience high infection rates in the spring.  Along with geographical seasonal factors, population density, age structure of the population and general health status of a population appear to be key factors associated with total burden of CV-19 illness.  The past pattern, likely driven by both virus infectiousness and behavioral factors, is for relatively short, sharp cases surges.  This would suggest that classic notions of percent of population infected for significant slowing of transmission are far too simplistic to understand actual epidemic courses.  More sophisticated modeling which accurately replicates heterogeneity in contact patterns, susceptibility to infection and infectiousness seem to produce more accurate depictions of likely epidemic course.

This section is more opinion, but I believe research and data support my assertions.  Our response to this epidemic has been unprecedented and unbalanced.  It has ignored all the consequences of mitigation or suppression tactics and focussed only on reducing cases and illness burden from CV-19.  In doing so, enormous economic, health, social and educational damage has been inflicted on the population.  This cannot be disputed.  This damage is directly attributable to our decision about how to respond to the epidemic not to CV-19 disease itself.  Evasion of responsibility for this damage is not helpful or transparent for the general public, who should be given full data on the consequences of actions so that at least in democracies they can express their opinions on the propriety of those actions.

We have also exaggerated the seriousness of the epidemic by testing and reporting disease and death in an unprecedented manner.  Mass media and politicians have engaged in hysteria, mass delusion, and terrorization of the population.  Political leaders have been unwilling to acknowledge the ineffectiveness and likely futility of most mitigation tactics.  Lockdowns, stay-at-home, closing schools, massive testing and supposed contact tracing, mask wearing, etc. clearly don’t have much of an impact.  Honestly, we need to accept that short of truly extreme lockdowns, literally telling people they cannot come out of their houses, it is difficult to slow transmission.  And you can’t lockdown forever, the virus isn’t magically going away, when you lighten up, cases will just start up again.  And why would you lock down so extremely when the burden of illness on the general population is simply not very high.

So resist the renewed hysteria and panic, do what you can to keep yourself and others safe, recognize that extreme suppression measures have a cost that isn’t justified by the benefit and do your best to be patient and wait this out.  It may roll over more quickly than we realize.


Join the discussion 16 Comments

  • Dave says:

    I always enjoy your posts but I am, for the first time, starting to get really worried. It seems in may parts of the country hospitals are filling up. Assuming there is some lag from cases to hospitalizations, this is likely to get worse. The 7 day average of new cases on 11/3/20 was 89230 and on 11/13/20 was 142,925. This suggests on 11/23 hospitalizations will climb another 50% and if the cases rise for another 10 days at this pace a catastrophe could be imminent. Hopefully that won’t happen and this sharp spike is about to peak, but I’m starting to think a short severe lockdown to knock this down a bit might be called for.

    • Kevin Roche says:

      Good observations.  Total hospitalizations are still within general capacity utilization for this time of year.  Flu is and likely will be down and other hospitalizations, some that should, are not occurring. For over a decade now, public policy has been to lower hospital use and lower capacity and run at high levels of capacity utilization.   Given the lag, a lockdown won’t change cases significantly, if it has any real impact, for at least a week, and then considering the lag to hospitalizations, we would still be seeing hospitalizations from the cases that started a week to ten days earlier.  Biggest impact on hospitalizations would be to allow remdesivir to be administered on an outpatient basis. 
      Given the typical seasonality of coronavirus and that everyone was talking about a fall/winter wave since the late spring, how can we be so unprepared?

    • Kevin Roche says:

      I am going to post some charts tomorrow showing current year right now hospital capacity utilization versus prior years. Generally under control. Staff out due to isolation may be a different problem. Beds but no staff doesn’t work.

  • Steve says:

    This has become and is a political tool. Reporting reminds me of daily death count during Middle East war that is when a Republican held the Presidency. After Obama was elected reporting disappeared.

    Somewhat the same with the china virus. If Trump is not re-elected you will see less reporting. The mission was scare the American people enough that they will want Trump out; looking like mission accomplished. At the same time many politicians grabbed more power and are drunk on it.

    We knew the fall and winter would see a return. Mostly because we keep hiding from the virus making us more likely to experience protracted events.

    This is the simple message they won’t turn out every day. If you are sick stay home. If you don’t feel well wait a couple days to see if you feel better if not check with your doctor. If you are in a high risk group be cautious,

    Of course common sense and individual responsibility left the building when America became Godless, self absorbed, ignorant and get this one PAID to stay home

  • DirtyJobsGuy says:

    Your previous post on what you would do reminded me of an old engineering director I had. If you went into his office for a technical meeting you had to write out the question you were trying to answer on his blackboard. If you couldn’t frame that question you were kicked out of the office until you could.

    I think early in the pandemic people sort of got the question but not totally. The popular slogan was ‘flatten the curve’ so hospital beds would be available. The second poorly stated aim was to minimize illness until a vaccine was available. These rapidly became “lock down to eliminate the virus” but this was never stated explicitly. If a serious effort was made without political gestures it would be apparent that that was impossible. An alternate question would have been “how to treat the virus more effectively” and “how to speed up successful vaccines”. In both of these I think great progress has been made. This should be the real effort of modest isolation and making sure everyone is aware of medical and pharmaceutical advances

  • Darin Kragenbring says:

    I would add that there must be an impact from the lockdowns earlier this year in regards to the delay of “non-critical” care. Granted, those cows have left the barn; however, the tactics we chose in the spring and early summer have a lasting effect. Whether it was people missing scheduled care or diagnostic appointments, that backlog seems to me to be a key driver in hospital capacity now. I haven’t seen a reliable measurement yet and hope that we are able to work through this excess demand on hospitals.

  • jamesbbecker says:

    I wouldn’t be surprised to find that the obesity risk is really a proxy for low vitamin D risk.

    Fat people don’t walk around in the sun very much, they aren’t that healthy, probably don’t take supplements, and their fat cells absorb Vitamin D.

    The amount of publicity and study of Vitamin D levels in the US has been way too inadequate. Its as if the people who decide where grant funding goes would rather not know.

    A non-scientific sample size of 1: I have a mildly obese 20 year old living in my house who got covid. He had mild symptoms, but he’s been taking 2000 IU/day of Vitamin D for a year.

  • Kenneth Felton says:

    Stop making sense! You’ll be getting a visit from the Ministry of Truth. The CCP virus crisis is a hoax. One that will disappear, if and when Biden’s handlers are sworn in.

  • Kate Craig says:

    Everything you say makes sense, except if you’re in New Zealand, Vietnam or South Korea. They can attest that contact tracing and enforced quarantines have stalled transmission. Many U.S. health care professionals insist we should do that here, but we have lacked “the leadership.” If a new leader is sworn in two months from now they may try it. Even though it seems unfeasible and we’re not a communist-controlled island, don’t be surprised if this is the solution they try.

  • Anthony says:

    Kevin, overall an excellent analysis, but I think you neglect two critical items.
    1) At least in the upper Midwest, hospital capacity UNDERestimates the current strain on the health system. >50% of my 700+-bed hospital and >50% of our 150 ICU beds are filled with COVID; 25/60 ED beds have COVID patients who have been waiting >24h for a bed. Main point: Even to be admitted now (vs. 1 month ago) one must be seriously ill. Unless one is hypoxemic, all others are sent home. This is frightening. I’m not contesting your abhorrence of universal lockdowns; indeed, I agree with you. But selective self-isolation is rational.
    2) That everyone will be exposed and many infected, as you suggest, is indeed inevitable. But DELAYING infection among the medium- and high-risk allows more time for effective therapies to be developed, and, as importantly, mass-produced. Case in point: Look at the release of bamlanivimab this week! An antibody that may abort serious illness in the most vulnerable. As an overweight, high-risk 64 y o with other comorbidities, I have been back at work, but at risk, since June (My employer will not allow me to self-quarantine without retribution; otherwise, i would do so) But when (not if) I get infected, therapeutics are much better now than a mere 4 months ago. (And, BTW, I’m much more likely to get infected by an asymptomatic co-worker than a CV-19 patient with signs on their hospital door. And I have seen many patients in my clinic who then manifested CV-19 merely a few days later. My N95, room cleaning, and HEPA units in each room have probably stemmed my risk).
    Carry on, sir, I will now be a regular reader.

    • Kevin Roche says:

      Thank you for the information, I should be careful not to suggest that the hospitalization issue isn’t serious, particularly in regard to staffing. I do think we will cope and not be overwhelmed.

  • DrDB says:

    The numbers put out by the media are garbage. Let me start with “cases”.

    Elon Musk was tested four times on one day. Two positives and two negatives. He is counted as two cases. But the last test was negative so he should be zero cases.

    If a pregnant woman shows up in the ER with severe abdominal pains. She is assigned to an MD or resident and becomes a case. If she is found to have bad gas she is sent home and no longer a case. If she is in labor she remains a case until the baby is born and she goes home. When that happens she is no longer a case.

    With SARS-CoV-2:
    People who have ever tested positive and are actually positive are “cases”
    PLUS people who are not positive and have never been positive but have tested positive anytime in the past are “cases”
    PLUS every time people that test positive are retested positive more “cases”
    PLUS many people that have never been tested “are “cases”
    PLUS some people that have T cell immunity but have been recently exposed are “cases”
    PLUS tens of thousands of lab errors and lab reporting errors are “cases”
    PLUS rampant health department data entry errors are “cases”.

  • L. E. Joiner says:

    “Another facet of the epidemic that should be very apparent now is a geographical, seasonal pattern that creates a far more hospital environment for the virus and transmission under certain circumstances.”

    Misprint: You mean ‘hospitable’ environment.

    Also, please remind us what ‘IB’ means.

  • DrDB says:

    It is not uncommon for hospitals to run at capacity. There is no point in having excess capacity as a routine matter.

    Florida is the exception. In winter we are nearly always way OVER capacity, and in summer way under.

  • researching says:

    Mass distribution of Vitamin D supplements, esp. to elderly?

    New study on “baricitinib” as a treatment option?

    actual paper:

  • Julie Rydberg says:

    Our Dear Leader, Tim Jung MN, is overwhelmed with the power he has been given and is seemingly unable to step back from it and look at this disease logically and rationally. His cure is worse than the disease, since most people get better just fine without hospitalization, but too many people are being denied needed services (like children in school, cancer treatments, veterinarian appointments for sick animals, and even things like haircuts for those who cannot wear a mask!). I can’t imagine how many battered women are stuck with an abusive partner who has plenty of access to alcohol, but no access to work. The number of mental illnesses that are on the increase and are not being properly treated has to be astronomical! I call this a “panicdemic,” rather than a pandemic.

    We need to protect the vulnerable populations, but isolating people will only increase fear, loneliness and anxiety. We need to find a rational balance based on actual science and not the governor’s made-up numbers (like that 5% number that mandated masks).

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