Monthly Archives: March 2020

I went to a two day epidemics and ethics conference around 2004. Some of the authors of this paper were speakers. This captures the challenge of what we are up against from the medical resource side during this pandemic. I highly encourage everyone to read this piece in the NEJM.

Separate from that, while I applaud the efforts to create alternate care sites, there are a few questions to keep in mind. Who is going to staff them? How are staff going to be given any PPE since they can’t get it in traditional hospital setting? How many of those staff are ICU trained and have any knowledge around the operation of ventilators that aren’t familiar to them?

Keep in mind that even if you aren’t infected by COVID-19, if you need to be in a hospital for some other reason, care could be VERY hard to come by. Think about everything you do. Don’t take unnecessary risks. Don’t drive further than you have to. Limit your exposure to others.

I keep seeing solutions stood up, but when it comes down to using these plans, I see a LOT of gaps.

There is only one major way that everyone can contribute.

STAY HOME

This one is going to be far more of a personal reflection. While I have seen a clear need to try to provide data, analysis, and useful information, I also think there are times when simply being completely vulnerable and human is going to be helpful as we go through this together.

I just came from the home of my parents. My father is in the hospital with aspiration pneumonia that has been a complication from Parkinson’s disease. I haven’t seen him for weeks now because of the no visitors rules which are in place, which I fully support professionally. Assessments and tests in the hospital have determined that eating is going to repeatedly cause more aspiration pneumonia. One solution to that is to use either a PEG or NG tube, which most people refer to as types of feeding tubes. Unfortunately, even with either of those devices, the evidence is pretty clear that he will likely still aspirate saliva, and pneumonia would become a chronic condition.

In addition, as part of the Parkinson’s disease process, there is a loss of fine motor control as well as a decline in cognitive function. These have both been very obvious, almost at a rate where there are clear changes in as little as week that we saw before placing him in the hospital. I’m sure these have been incredibly depressing to him since he cannot do things independently anymore.

I had a friend of mine write about the need for Advance Directives and how important they are for family members just six days ago. I remember reviewing these with my parents a number of years ago and we pulled out the one for my father today.

Even though he is lucid at times now but confused at others, we had a document to look at from when it was clear what his wishes were. The other thing that I also had in the back of my mind in conversation with his doctor today was that we could certainly keep treating him aggressively for quite some time and it would slow his death, but it would not stop it. Not only would that add some suffering because of the barrage of ongoing tests and assessments, but as we go through the pandemic, he would also be occupying a bed that could be used for someone with a better prognosis and also free up clinical staff and support staff to care for others.

We took his wishes from his Advance Directive as well as talking about what the medical needs are going to be in my community shortly and decided to start the process of hospice care. All we are waiting for is to schedule a call with the hospice nurse to figure out how to make that next transition as part of end of life care.

It’s hard. All I’ve had on my mind since the beginning of February is death from my professional lens, which also carries a lot of emotion with it. From a personal lens, I knew this day was coming. Maybe that helped me be ready for this moment. I don’t know. I am feeling all of the crushing emotions that are coming at me from all sides right now in a very concrete way. I know that others are currently in the exact same place, but what really hurts is knowing that soon that will be millions of people. I grieve for every single one.

March 24 Update: Other research indicates longer survival times so I’ve changed the recommended number to match throughout. A five day quarantine looks to be effective for most materials that will be coming in from outside the home.

Previously, I had talked about keeping a temperature log of family members as a means of establishing baseline ranges and to move someone who is ill to separate quarters if possible. There is also some CDC guidance for households as well.

First, if you have hand sanitizer, put a bottle at all entrances to your home that are used, or if you don’t have enough, one at the most common entrance. People should use it immediately on entry. This is pretty much a standard procedure when going into patient rooms in hospitals. This will help keep you from spreading virus around in your home if your hands have become contaminated.

Second, I want to add some other related to objects you bring into your home. There is some research in the NEJM talking about the survival of the virus on surfaces. Using that, I decided how I’m going to quarantine goods coming into my home. Overall from these studies, it appears that 5 days should be the magic number on the surfaces studied. That doesn’t mean that it guarantees that it will be gone after that length of time, but that there should be a considerable reduction in risk of virus being on that surface. It’s a shorter time depending on the surface type, but to keep it simple and not have to remember those details, I’m going to use 5 days for each.

Mail. I’ll rotate out five bags for mail when I check my mailbox. After five days, I’ll feel pretty comfortable opening the mail inside the bag and then using that to get that days mail.

Delivered packages. Unless there is something perishable, is there any hurt in putting it in your garage for five days? Perform hand hygiene after moving them. On a side note, the entrance from your garage into your dwelling is an excellent place for some hand sanitizer.

Groceries. This might be a bit trickier. I’m hoping to keep dry goods, frozen, and refrigerated in separate bags. Dry goods are easy. Five days before coming out of their bags.

I’ve set aside separate spots in my refrigerator and freezer for those purchases and have told my family members which spots are off limits. If you are getting groceries more frequently than that right now, WHY?

Pets. Yes, most people love animals and want to pet them. However, I’ve had a number of people ask me about this. I wouldn’t pet anyone else’s dog if out for a walk. However, if you absolutely can’t resist, bring some hand sanitizer along so you can disinfect your hands as soon as your done with your canine encounter before touching anything else. If the owner is sick, it seems theoretically possible to have gotten virus on the dog’s coat. If I had a dog I was taking for a walk, I would ask people not to pet it, because you simply cannot know the hygiene habits of others.

This is the most clearly written summary of all of the things I’ve been trying to communicate related to why we need to crack down hard to get COVID-19 under control. It’s a long piece, but I urge everyone to read it carefully.

I used to be on the board of a nonprofit organization named ECHO. They were eventually integrated into our local public television station. Instead of trying to describe what they do, I’ll just copy the information from their website.

“ECHO Minnesota is a nonprofit organization dedicated to connecting immigrant and refugee communities to health, safety, emergency preparedness, and civic engagement. Multilingual and culturally-specific education, television broadcast, web-based videos, outreach, phone lines, and training are all supported by a network of 200 organizations and 65 bilingual spokespeople. With this support AND with donations from the community – ECHO Minnesota is able to help New Americans to be healthy, safe, prepared, and engaged.”‘

I should have thought of this sooner because I knew that they would have pertinent information related to COVID-19. Please share this link with contacts you might have that need some of these messages in their own languages in their communities.

I’ve been accused of making things sound worse than they will be. I’ve actually tried to keep the things I wrote far more to the conservative side of the estimates of the impact of COVID-19. If I painted the real picture I had been expecting, I probably would have been discounted as an extremist from the chicken little school of epidemiology.

Now, however, I can start making a much more dire prediction of the future. I’ll be making new impact models on the US using more current data that will present a more accurate scenario of the future.

It’s really not that hard to model and one physician has done a video to explain just how bad things will be. I’ve been warning you.

Stay home. Stay safe.

One useful way to look at the disease burden in a community is to look at the increasing case counts for different areas but normalize them to a common starting point. For this view, I selected the first time a location reached at least 100 cases to count as day one. This allows a reasonable comparison of the explosion of cases in a particular location.

First, look at a comparison of different countries. I’ve left China out of this analysis. Clearly, the worst disease burden outside the US has been in Germany, Italy, and Spain (red lines) closely followed by Iran and France (orange lines). Look at the US though (black line). We look to be on a far worse exponential grown curve than any other country. It’s also likely that this is very underrepresented of the true case totals because of the lack of extensive testing in the country.

One thing that can also be learned from this graph is that there are three countries (green lines) that have had a very good to exceptional response to COVID-19 (South Korea, Japan, and Singapore). We really should be looking to them as the leaders in how to contain this problem.

Next, look at the three countries outside of China that had the first local outbreaks and the three US states where case counts climbed first.. There’s only one thing I want to point out here that should be obvious looking at the graph. New York is in major trouble.

I wish I had thought to put this reference up earlier. I was on a committee that addressed respirator shortages with guidelines from our professional association for reuse. Share this with hospitals.

Find the link here.

There is a very good chance that we will not see just one wave of the pandemic in different geographical areas, but multiple.

Early, I talked about the reproduction rate of a disease, or R₀. For the incident rate (number of new cases in the population) to fall, the R₀ has to be less than 1, or to put it in English, each person with the disease has to spread it to less than one other person.

Rabi et al. state “Estimates of the R0 of SARS-CoV-2 have ranged from 2.24 to as high as 3.58 [31] although the World Health Organization estimates it is between 1.4 and 2.5 [32]”

The R₀ allows us estimate what level of either infection and recovery or vaccination is needed to provide sufficient herd immunity to stop disease transmission in a population. Fine et al. provided a model that is useful.

My takeaway with just an eyeball assessment of the graph is that we will need to have around 40-65% of the population immune through either illness and recovery or vaccination when that becomes available. My models have been based on only 20% of the population being infected. That is a terrifying thought based on how high the morbidity and mortality could be by increasing that attack rate by 2-3.5x what I had previously calculated for mortality or for the hospital surge model I’ve built.

Be prepared for the long haul with COVID-19. This is going to take months to well over a year.

Stay home. Stay safe.

Two days ago I finally revealed what is my biggest fear of the secondary impacts of COVID-19 – that hospitals will be overrun and unable to provide care. I’ve had people tell me that I am overreacting and that our system can’t handle it. The fact is, whether someone denies it or not, I’m correct. There was a story in the New York Times today that talks about that becoming real very soon in the location where I said this problem would first emerge – Seattle.

Do you need more ideas of what the future looks like as they approach that precipice? Watch the video on this page. It’s in English. Maybe this will awaken you to the harsh reality that I’ve been trying to warn about all along. Does that make me alarmist? It seems to me only to be the case among those who want to deny the facts. I simply want people to take this seriously and stay home so we don’t have it as bad here.