Gambling With Your Life—The Opening Experiment COVID-19 Update—June 14, 2020
We need to have the courage to address our reality and stop living in a fantasy world. As the effects of the May openings tally up, the numbers of positive daily cases have reached all-time highs in Texas, Florida, California, Arizona, Alabama, Arkansas, Alaska, Nevada, North Carolina, South Carolina, Oregon, and others, along with increasing hospitalizations in most (1). Many additional states are showing steady case increases with higher percentages of positive tests, meaning the increased incidence is not due to greater testing. Because our government did not prepare enough to emerge from lockdown in a responsible manner, many areas of the country have basically wasted the gains we’ve made over our three months of lockdown. As another way to look at current trends, the LA times compared Johns Hopkins’s 7-day average of new state cases to the numbers from two weeks ago and noted improvements of at least 10% in 24 states, worsenings of at least 10% in 23 states, and less than a 10% change in four. With over 25,000 new cases Friday, the U.S. infection rate is flat only because we have swapped the areas of the country being ravaged by COVID-19, but the national rate will likely increase to a higher level soon.
Unfortunately, there is a time delay before we can observe the results of our behaviors and actions with regard to COVID-19. The incidence of positive tests (and specifically the proportion of positive tests) is the timeliest metric of infection with a lag of one to two weeks, while death-rates reflect disease transmission from around a month ago. The continued relaxing of social distancing restrictions and the recent protests against racial injustice will propel the number of cases to even greater heights in the next few weeks.
Every interaction you have with people carries a risk of infection. Wearing a mask properly when in public is the cheapest, easiest way to protect yourself while allowing our economy to reopen. Please think seriously about how much you’re willing to gamble with your life and the lives of your loved ones. A nurse who spread the infection to her mother is tormented by her mom’s resultant death and cannot forgive herself. Don’t let this happen to you or your family. The CDC projects U.S. deaths to reach 124,000 to 140,000 by July 4th, though I believe it will be closer to the high end if not higher since we’ve just surpassed 114,000, and cases continue to accelerate.
How do you assess your personal risk?
Not every locale is a hotspot for COVID-19 transmission—it occurs mostly in patches around a state like brush fires here and there and often shows peaks in nursing homes, prisons, jails, meat-packing facilities, and churches, but more widespread community transmission is also happening. Look at your city and county data. One county may be rife with cases while another next door may have few. If the data show few infections, hospitalizations, and deaths in your area, and especially if these numbers are decreasing, you may not need to be as worried, but since the data change constantly, stay informed. Know that many states and counties are not meeting the CDC’s suggested guidelines for reopening. Here’s a great resource showing the opening guidelines met by each state: https://www.covidexitstrategy.org/
How do you minimize your risk?
1. MASKS!
Wearing masks greatly reduces the spread of infection and can help get our economy going again and our kids back in school. Keeping people safe and rebooting our economy go hand-in-hand. People who claim we must choose between the two are creating a false dichotomy. The economy is unlikely to recover without universal mask precautions. If COVID-19 surges out of control again as it did in New York City, that locale and its economy will be shut down either officially or unofficially as people refuse to leave their homes.
It’s deadly unfortunate that the CDC and the WHO have created confusion over mask use and have been inconsistent in their messaging during this pandemic. More than fifty countries now require face masks in public. According to a British modeling study released Wednesday, population-wide face mask use could reduce COVID-19 transmission to manageable levels even without lockdowns in some cases (2). These analyses help to explain why some countries with ~100% public facemask use have experienced significantly lower rates of infection and deaths. A recent WHO study further supports these conclusions (3). A different study estimates that between April and May, public facemask mandates alone were associated with 78,000 fewer infections in Italy and 66,000 fewer in New York City though this study is receiving significant criticism for their methods (4). Regardless, multiple lines of evidence suggest that mitigation strategies like social distancing in the U.S. will not adequately protect the public without mandated face coverings.
ASYMPTOMATIC PEOPLE DO SPREAD COVID-19 and likely make up a large proportion of disease transmission as shown by the Scripps Research Institute analysis of 16 cohorts of COVID-19 patients (5) and a Japanese study analyzing the disease spread on the cruise ship the Diamond Princess (6). Please ignore the idiocy of the WHO this past week. Pre-symptomatic patients are another major concern since viral load peaks just prior to symptom onset and is thought to play a major role in superspreading events. Pre-symptomatic and asymptomatic carriers of SARS-CoV-2 may spread roughly HALF of infections, which helps to explain why the pandemic has been so hard to control and also why having everyone wear masks is so effective in stopping it. Someone can feel perfectly healthy and yet unwittingly spread the virus to another who may die from it. Without universal mask precautions, the silent carriers will continue to infect people, and we’ll be unable to contain the epidemic.
2. Maintain good hygiene (wash hands, don’t touch your face, disinfect surfaces that might be contaminated)
3. Limit contacts considering their risk profile and carefully choose any close contacts to add to your bubble
4. Social/physical distance OUTSIDE as opposed to inside –eating and drinking pose a more difficult situation since you have to remove your mask. Only do so if you are at least six feet away (really the minimum should be 13 feet) from others who are not in your family bubble. If you must be inside, an open space with good ventilation or open windows should be better than a small, enclosed space.
5. DO NOT spend long periods of time indoors in places other than your home. The virus can build up in the air indoors. Keep any risky activities very short.
6. Try NOT to use public restrooms or to even be in their vicinity. Aerosolization of fecal viral particles occurs with flushing.
7. Get tested immediately if you feel ill or come into contact with an ill person. If infected, try to trace contacts yourself in case your public health system’s response is lagging.
But isn’t our county following guidelines to re-open safely?
Be wary—some states, cities, and counties are ignoring their own guidelines, softening their guidelines or are manipulating their numbers to meet the guidelines for reopening (hello, Florida). Also, these guidelines assume we will be able to test, trace contacts, and isolate those infected at rapid speed. I’m sorry to tell you, but we’re not there yet as my friend’s experience with COVID-19 will illustrate. Americans never isolated at home to the extent that most Europeans or Asians did. Though some citizens took the restrictions seriously, the majority did not, and our “lockdown” has looked more like Sweden’s minimalist approach, which has been widely criticized and ineffective.
My 51-year-old friend in Orange County, California has been in the ICU recovering from COVID-19, and without Remdesivir, he might have died. He, his son, and grandson all contracted the disease, and their positive test results took two-plus days (one from an ER and two from drive-up tents). No contact tracing was performed for any of them (actually, I have to amend this—they did contact my friend 11 days after he tested positive, which is NOT helpful). I was outraged and cannot imagine Orange County is meeting its guidelines well enough to justify any easing of restrictions. With a fast-spreading virus, time is life. We cannot squelch this pandemic if my friend’s experience is similar to what is happening elsewhere in this country. We need test results in hours at most, not days. We need to alert all contacts to isolate within twenty-four hours before they start spreading the infection pre-symptomatically. We are not ready for an increase in infections. I’m not sure what our government has been doing over the last three months, but they have not adequately ramped up our ability to combat this disease with testing and tracing. To top it all off, we still don’t have enough personal protective equipment (PPE) for healthcare workers, who are still reusing PPE in ways not recommended. We certainly do not have enough for a large increase in cases.
It is likely too late to prevent a second peak within this first wave of infections in many locales, but widespread mask-wearing could help us turn the tide. Also, if we were testing and tracing as we should be, all public health entities in cities across the country should have already encouraged anyone who attended the protests to obtain free COVID-19 testing even if symptomless. The Facebook group for San Diego Protests does recommend this to some extent, but I have not heard it mentioned anywhere else. If we’re serious about contact tracing, this proactive approach is key to isolating those with infection and their additional contacts before an outbreak takes place.
Assessing the level of risk you’re willing to take is a personal choice, but I hope you’ll consider wearing a mask to protect yourself and others, to help our economy recover, and to decrease the risk to healthcare workers. Wearing a mask and staying home all the time is no fun, but if you’re careful, you can start doing some “normal” activities if precautions are in place.
What is my family doing to minimize risk?
In San Diego, our rate of infection has been relatively low, and masks have been mandated in public spaces for weeks. Unfortunately, COVID-19 cases are starting to tick up, and we’re teetering close to having to reverse some “openings” because of four recent indoor public outbreaks (a restaurant, an office, etc.). This week, I went to a few postponed medical appointments and had my dogs groomed but only because these businesses are strictly enforcing universal masks and safety precautions (though a large number of people, including a medical assistant, wore their masks incorrectly). Up to this point, we have had very little outside contact except for infrequent grocery shopping and weekly takeout after masks were mandated.
The emotional well-being of my teenagers has suffered during this isolation so we’re considering establishing a bubble with another family, but we have to make sure we’re completely on the same page with regard to risk first. We’re also going to allow them to have socially distanced outside meetings with a few friends at a time (all masked and six feet apart).
My gym is opening up, taking many precautions EXCEPT for making exercisers wear masks while working out. This crosses the line for me. I won’t be returning until they mandate masks or we have a very effective and accessible therapy or vaccine. My elderly parents live with me. I will not risk the lives of my family to exercise at a gym.
If you aren’t wearing a mask in public, you’re showing that you do not care about your health, anyone else’s health, or the economy of our country, and you’re endangering the lives of healthcare workers who have been severely mistreated and under-protected by their employers and our government. Every single time you are out in public in the vicinity of others, you need to wear a mask (and for God’s sake, wear it correctly—cover your mouth and at least half of the length of your nose, wrap it under your chin, and keep it in place). Encourage everyone you know to wear one. We don’t have to wait for a scientific breakthrough to improve our circumstances. Wearing a mask is a simple, inexpensive effort we can personally make to save our country from this pandemic.
Stay Safe! Stay Healthy!
References:
- An interactive visualization of the exponential spread of COVID-19
http://91-divoc.com/pages/covid-visualization/
- A modelling framework to assess the likely effectiveness of facemasks in combination with ‘lock-down’ in managing the COVID-19 pandemic
https://royalsocietypublishing.org/doi/10.1098/rspa.2020.0376
- Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31142-9/fulltext#%20
- Identifying airborne transmission as the dominant route for the spread of COVID-19
https://www.pnas.org/content/early/2020/06/10/2009637117
- Prevalence of Asymptomatic SARS-CoV-2 Infection
https://www.acpjournals.org/doi/10.7326/M20-3012
- Natural History of Asymptomatic SARS-CoV-2 Infection
https://www.nejm.org/doi/pdf/10.1056/NEJMc2013020?articleTools=true
