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What Next with COVID-19?

Ok -- I can't any longer resist the temptation to say what I think about the next steps in this covid crisis ... these are my own thoughts as an "unfrozen caveman biostatistician" and layman -- I am not a doctor or hospital administrator or leader.

The social distancing we have practiced the past month or so seems to have really made a difference -- the virus spread has been slowed, we have clearly "flattened the curve", and most of our hospitals have been able to handle the load very well with the exception of a few hot spots. This has probably also been helped by the sense that ventilators are not the front line strategy that we thought they might be -- that they are being used less than expected, and our health care professionals have learned that they should probably not be used too often. We all thought the limiting factor in the healthcare system was number of ventilators, and maybe that is not so much the case, which may mean our system can handle things better than we thought. The incidence and deaths continue to climb, but the rate of increase has leveled off and seems to have reached an inflection point for now.

What now? Some people seem to be implying we should "open the economy" and perhaps go "back to normal." Others say that once we relax social distancing, there will be a new surge, and so we need to continue it, maybe indefinitely until we have a vaccine or better treatments.

I reject both of these extreme positions. We can't just go back to normal as this virus really spreads fast and is super nasty. But we also can't live like this much longer either. The shutting down of the whole country/world is bearing consequences that if we continue are dire themselves, economically, socially, psychologically, physically, educationally, intellectually. We humans are complex creatures and live in a complex world and we can't just shut down the whole system for 12 months, 6 months, or maybe even 4 months. The repercussions are unthinkable.

The key questions is "Is there a way for us to mitigate/manage the virus in a way that is less extreme and less disruptive?" This is the key question for our societies to answer now, and we need to get all the political crap and posturing and blaming and trying to push personal agendas out of the way and address this question together with a team-oriented approach. Hard to do in a key presidential election year with super-polarizing president of course but we have to do it.

What have we learned? Here is my understanding of key facts: 1. A lot of people that get this virus are asymptomatic for a while, and many never develop symptoms at all. Maybe >50% of people never get symptoms, and many others don't show symptoms for a while. 2. The virus spreads really really fast, and even spreads from asymptomatic infected. This is the REAL problem with this bugger. If not communicable until someone was sick, it would be much easier to manage, but a single infected person can literally spark a spread to thousands of people. Yikes. 2.5 There are a LOT of clusters of cases that come from super spread events -- from nursing homes, apartment complexes, from large conferences, funerals, or other gatherings. 2.75 Plus all of Manhattan is pretty much a large gathering based on the lifestyle that was followed in all of its glory all the way up until 3/22 or so, so the entire city is itself a "super spread" event that accounts for a huge proportion of total cases in the country. 1/3 of USA cases are in NY state, and probably ¼ or so of USA cases in NYC. Also some super spread in other cities like New Orleans and Detroit, but NYC on a whole other scale. 3. The virus seems to spread to some degree through the air, and remain on surfaces for a long time. 3.5 The virus may or may not spread less efficiently in hot, humid weather. We don't really know but the seemingly relatively slower spread in warmer, more humid climates seems promising to me. 4. Of the 1/2 that show symptoms, ~80% only get mild symptoms, and then get better. This means we have to be VERY careful in treating mild patients to make sure we "do no harm" 5. About 15% will get moderate symptoms, and may require hospitalization and/or oxygen for treatment of their pneumonia, that presents in a very distinct and unique way into both lungs, and a trained radiologist can know 100% he is looking at a covid patient even without a PCR test. 6. The remaining 5% or so progress to severe disease, and many of these require ICU care, and this severity seems to be typically caused by an autoimmune response, cytokine storm that overwhelms the lungs and leads to oxygen deprivation and organ failure. Treating and preventing this cytokine storm may be the key to preventing deaths here. Maybe that is the mechanism we should be looking at for treatment, not antiviral? 7. Sometimes this requires intubation and ventilators, although there is some evidence that ventilators have drawbacks and might be good to not use too soon, and that many patients do not come off ventilators and can be on for very very long time. 8. Testing availability has been a major problem in the USA, but has been overcome recently with increasing availability of tests including many rapid tests. The rapid tests giving results in minutes enable much faster testing not previously available. 9. Various treatment options are being tried, seems the most common include Remdesivir, Hydroxycholoroquine with or without antibiotics (Zpack), Lopinavir and Ritonavir, and a few other things. We have some limited positive evidence for Remdisivir, some mixed results from Hydroxychloroquine, and some negative results from Lopinavir and Ritonavir. But we know very little, and given the extent these treatments are being used off label and large number of trials investigating them (in clinical, >75 trials for HCQ, >25 for lop/rito, and >10 for Rem) with fast accrual, we should know soon whether any of these work and in what situations they work, and in what situations the risk/benefit is favorable enough to use. Additionally, there are studies and other use of plasma donations from infected+recovered patients to critical patients to give them targeted antibodies. 10. We now have antibody tests rolling out that can detect whether someone was exposed enough to the virus to have antibodies in their blood. It is thought, but not known, whether this indicates some sort of immunity. There are some reports of reinfection, or at least situations where the virus seemed to have resolved but was dormant and reemerged. 11. A vast majority of the critical patients have comorbidities, and obesity, heart conditions, and lung conditions, and diabetes among the most common and difficult, and/or are much older (and also tend to have comorbidities).

We still have a lot to learn, but given what we have already learned, is there a less invasive option we can use to mitigate the spread and manage treatment for the cases? Consensus is that this virus will be with us for a long time, so we have to learn to live with it around us and find a way to manage it. I fully agree. We have to figure it out, and real real soon.

Some ideas off the top of my head: 1. We should clearly limit big gatherings, since the super spread events are a big part of how it spreads. 2. We should all wear masks in public. The key is that if I am infected but asymptomatic that will prevent me from spreading to others if out in public. 3. We need to do extensive and rapid testing. Health care professionals and vulnerable populations especially, but when people have any potential symptoms or exposure to someone who was sick. 4. We probably need to do some type of monitoring of infected people, through smart phones e.g. like South Korea. Controversial and invasive, but this would allow us to track and control spread and allow other things to open up more. Are we willing to allow this type of invasion of privacy in this country? Note: the supposed "anonymized" data mobile phone companies have and throw around can easily be identified to figure out the precise identity of any one person in probably 30 seconds with 2-3 google searches so we may not actually have that privacy right now anyway (if you have location services turned on on your phone for anything). 5. We need to learn what the blood antibody tests tell us – does it yield immunity or not? If so, then people with positive antibodies could be the workers in hospitals working on the front lines, e.g. If it doesn’t yield immunity then let’s not pretend it does. 6. Given steps like these, we could allow reopening of certain aspects of society. Of businesses, of workplaces, of laboratories, of schools, of churches. 7. In the coming months we will get results of solid scientific studies of all these potential treatments, and learn what the antibody blood tests does or does not tell us. By the fall and next winter we should be much better equipped to effectively manage things clinically. 8. The vaccine studies are moving forward -- I hope we may have at least preliminary indications of whether they seem to work in 6 months or so even though it will take longer to definitively establish efficacy and toxicity.

The reopening will yield more cases, but if done carefully will be slow enough to be manageable, “keeping the curve flat”, while also mitigating the economic, social, and psychological effects we are inflicting by forcible stay at home policies. Social distancing will NOT kill the virus and make it go away, it will slow the spread. My opinion is we need to do it in a careful way that is least obtrusive as possible. To my mathematician friends, it is trying to find the “global optimum” that balances out all different aspects of life, not just the “local maximum” that optimizes control of the virus but severely suboptimal in other ways, or that tries to optimize the economic recovery but allows the virus to spread out of control again.

I think behind the scenes these discussions are going on and I hope done with wisdom and collaboratively taking all viewpoints and expertise into account in a team-oriented approach. The temptation of people with agendas to use this opportunity to push their poison is great and we need to filter through all of that.

I am optimistic that we can get it done, but it is going to be a long road.

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