COVID-19 Update as of April 20, 2020 (8:00 PM EST):
Uncertainty is being removed regarding COVID-19 impact and timelines in US:
NY/NJ social distancing announcement of extending to mid-May.
Reopening guidelines have been issued by the federal government.
Decisions will be made when to open on a state-by-state basis by governors.
Are the CDC and FDA answering the right question?
Testing for the virus has existed from other countries that have controlled COVID19 (South Korea). But these tests are not accurate to the level of CDC and FDA standards (80% accurate vs. 95%+ accurate).
Is 80% accuracy good enough to significantly slow the spread and reopen society now? Or is the goal to get 99% accuracy testing with adequate supply available maybe several months from now?
Is the goal to scientifically define the death rate accurately? And if we wait for more accurate testing, will it change what our country will be forced to do anyway by June or July at the latest -- to reopen businesses?
Several states have likely reached their peak of hospitalization rates and discharges have begun to surpass new admissions.
The University of Washington IHME forecasted the peak time of hospital utilization and deaths as referenced in updates provided by multiple governor daily briefings.
The assumptions made in these projections are that “social distancing” will remain in effect until May 31. Actual results change these future projections daily.
As of April 6, 2020, projections are as follows:
US peak hospital resource demand: April 15
US peak deaths per day: April 16
NY peak hospital resource demand: April 8
NY peak deaths per day: April 9
NJ peak hospital demand: April 15
NJ peak deaths per day: April 16
As of April 2, 2020, the University of Washington IHME forecasted peak times in hospital demand and daily death rates by country and states. Note, the forecasts change daily based on real-time data:
How will America get Back to Work?
There is a 4-pronged medical approach to ensure we can sustain removing social-distancing policy with a minimum pf resurgence of cases. This is with social contact surveillance across all:
Quick Result COVID-19 Testing: Abbott has launched (currently available, capacity to supply up to 1 million test kits per week) with 5-15-minute results. This will help us to know who to isolate. Test results have taken between 5-7 days prior to launch of recent quick-test alternatives.
Recognizing some patients received more than one COVID-19 test as of April 6, 2020:
US: 1,795,855 tests conducted (0.55% of population)
NY: 302,280 tests conducted (1.55% of state population)
NJ: 82,166 tests conducted (0.93% of state population)
There has been a shortage of available test kits and/or associated components (i.e. swap, reagents, test results).
Development of testing for the infection has been constant and rapid. Since February, the FDA has been issuing a steady stream of Emergency Use Authorizations (EUA’s) for COVID-19 tests to various organizations listed below:
Developments will continue to improve the testing process in various areas:
Rapid testing: Abbot Laboratories Id-Now platform can diagnose an infection in as little as 5 -15 minutes. Such technologies (especially those that can be run at the point of care) greatly reduces lag-time in knowing which patients to isolate. The test requires a machine to analyze the results which costs $12,000-$15,000. The FDA, up to this point has approved this test for use only at medical point of care sites (hospitals) and diagnostic labs such as Roche Diagnostics, Quest and LabCorp. This likely will have to change to allow business to conduct testing on-site.
Self-administration: United Health Group conducted a study in Washington showing >90% of positive cases detected in which patients self-administered the swab portion of the test. The FDA has allowed self-administration as a result which decreases exposure and time spent by healthcare workers for testing. If self-administration of testing is approved, the swabs would still have to be sent to a lab for analysis with several days until results are known.
At-home testing: As an alternative to rapid testing, Everlywell is working to roll out an at-home testing system in which kits are delivered to homes and then shipped directly to laboratories with results posted online in the next few days. Such a process could ease strain on testing facilities and limit short-term exposure.
In the short-term, infrastructure of the testing system is a limiting factor--from availability of healthcare workers to manufacturing supply of the tests themselves. In the future, as the disease spread is slowing, these advancements will lead to a healthcare system more robust against further outbreaks.
2. Test For Exposure to COVID-19: Diagnosed / Undiagnosed and have developed antibodies to the virus.
It is not known for certain medically but believed that if a person has been exposed to COVID-19 they are highly unlikely to contract the disease again (for an unknown period of time) due to building up immunity to it, low risk to go back to work – Cellex has been granted an EUA (Emergency Use Authorization by the FDA) for antibody testing on April 1 for a quick 5 minute test to determine exposure to COVID-19. New York Department of Health is also being granted FDA EUA for an alternative antibody test. Both the sample collection and analysis of the results of this test would have to be analyzed through a certified diagnostic lab at this point. It is unknown supply capacity and/or unclear the duration from contracting the virus to being detected by this test method will be valid. Outside the US, several blood tests are in use, where the patient self-administers the test, uploads an image of the result in minutes, and sends to a certified doctor or nurse to analyze the results and send back the diagnosis of whether a person has been exposed. These tests are not approved by the FDA for US patients because the accuracy of the results is below the FDA accepted threshold.
3. Drug Treatment with an antiviral if a patient contracts COVID-19
Antiviral treatment testing is in progress (end of Q2/2020 data) This is pending for treatment and not for cure for COVID-19. Drugs are available for off-label prescribing use now including plasma exchange from previously infected and recovered patients to severe symptom patients). Drugs in development include:
Vaccine Prevention of COVID-19
Several vaccine options being studied (available Q1/2021 at the earliest?). There is high probability a vaccine will work unless COVID-19 starts to mutate. There are no signals of that yet. Manufacturing capacity scale-up, once approved, will be limiting the rate of vaccine availability to the broad population. Vaccines in pipeline include:
Reasons to be positive of our ability to control COVID-19 impact:
> China was on lockdown for 9 weeks (>10 weeks for Wuhan epicenter to be lifted April 8)
> Italy and Spain appear to be leveling off
> US is about 2 weeks behind for NY/NJ region and NY appears to be leveling off over past week as well.
> China has controlled spread with leveled confirmed cases over a week – so this can be controlled with the right public policies
COVID-19 Data and Trends for Select Regions
Update as of April 19, 2020 (8:00PM EST):
All data referenced is from CDC, WHO, census data, and Bing-COVID-19 tracker that correlates very closely to Johns Hopkins University case tracker.
Note: All graphs include data points from March 20 through April 19.
In general, and if the information is valid, China took 10-11 weeks to stabilize the death rates with Draconian measures that the US is not instituting i.e. arrests made if not distancing from people, etc.
We are 2 weeks into lock down for some states – this is not effective if people are continuously driving over state lines -- so our policies will take much longer to control it.
Unfortunately, the only metrics with reliability are deaths; and more meaningful deaths per 100,000 population. This could vary because not all since cases are known and testing is minimal and inconsistent.
It is impossible to know the level of new cases identified vs. new cases transmitted to people as testing ramps up in the US.
The actual number of deaths is a legitimate measure, however is also a lagging indicator of reaching a “Plateau in cases” (as shown in graphs below):
New Jersey alone has nearly equaled China in confirmed cases:
US has passed China in confirmed cases:
US confirmed deaths have also surpassed China at the end of March (as shown in graph below).
Good news: China has stabilized the number of deaths after 9 to 11 weeks of complete lock-down which means with the right public policies, the COVID-19 impact can be controlled.
NJ and NY are at 5-6 weeks of lock-down currently. Meanwhile, only portions of the rest of the country have been on lock-down, are currently on lock-down, or just recently announced a Social Distancing state-wide policy.
Without a national policy of Social Distancing and working from home for non-essential employees, it is highly unlikely the US will control the COVID-19 spread for several months without a vaccine being available (12-18 months) or rapid 5-minute test results available on the order of 50 million + test kits (several months minimum for availability until the supply capability is reached).
Deaths per 100,000 people (per capita) for selected regions plotted – NJ is the highest in deaths per capita in regions shown and is now worse than Italy and Spain.
>> Not graphed…New York is only region higher deaths (per capita) within US – with a death date per capita twice as high as any region on earth analyzed as of today:
Keeping things in perspective vs. seasonal flu, COVID-19 has just exceeded number deaths caused by the flu per year for the US:
Keeping things in perspective vs. seasonal flu for New Jersey:
The number of deaths by COVID-19 for New Jersey in the past 8 weeks alone is now 3 times more than deaths caused over the course of an entire year from the seasonal flu:
So Why all the Closures and Social Distancing Self-Quarantines?
US population is around 330 million
US had 35,520,883 symptomatic flu cases in 2018
US had 34,157 deaths from the flu in 2018
We know how the flu spreads given the history of exposure hence a natural level of immunity; and the flu shot has been developed. However, all indications point to COVID-19 spreading much easier.
COVID-19 – one scenario without any control measures that seems reasonable to look at:
Assuming the US does nothing: COVID-19 cases should equal at least 2-4 times higher; or theoretically speaking, 2 times higher than the flu without any control measures i.e. quarantines.
US flu kills 1 in 1,000 people, and resulted in 34,157 deaths in 2018
COVID-19, surmised at this point, is 10 to 43.8 times deadlier as a range based on actual current data. Although this could be a low a 3-7 times deadlier if testing was wider spread and cases identified.
Without any control measures, we would expect between 700,000 – 3 million US deaths from COVID-19 over a course of a 12-month period given this scenario set of assumptions.
COVID-19 without control measures: 700,000 – 3 million die in US compared to:
Civil War US deaths: 750,000
WWII US deaths: 405,399
WWI US deaths: 116,516
Vietnam War US deaths: 58,209
Korean War US deaths: 54,246
Many other assumptions can be made that would look a lot worse, and of course a lot better, if we can limit exposure to buy time for a treatment or vaccine development (longer term) and/or ensure hospital capacity for ventilator treatment (shorter term).
COVID-19 Discussion Points and Relative Perspective
Some talking points that I found to be helpful when discussing why we are under a “Social Distancing” policy. This may be useful for explaining this to family and friends, especially in regions not hit as hard as New York and New Jersey--yet.
If folks understand why they are being asked to self-quarantine they are more likely to do so.
COVID-19 is not the flu, it is a form of Coronavirus as is SARS and MERS.
COVID-19 is thought to have a higher infection rate than the flu:
Research estimates each COVID-19 infected person will transfer to 2-2.5 others, compared to 1.3 for the flu.
The flu is contagious once symptoms appear (and 3-4 days after symptoms appear).
COVID-19 is contagious before symptoms appear (2-14 days after contracting when carrier is still appearing healthy), while symptomatic, and also unknown time period after symptom recovery (3-37 days). This total time is up to 2-3 months.
80% of COVID-19 carriers are mild/moderate that are not being diagnosed and will not end up in hospital. But they are contagious with flu and cold-like symptoms that can easily and unknowingly transmit the disease.
Elderly and those with chronic cardiovascular, diabetes or immune compromised conditions are at a much greater risk of dying if they contract COVID-19.
Younger (20-54) are at a lower risk of dying, but still have a significant risk of spending several days or weeks in an ICU unit on a respirator.
COVID-19 is believed by scientists when including asymptomatic patients to be around 7-10 times deadlier than the flu:
It is too soon to know since most confirmed cases are severe that have been tested/diagnosed.
Depending on the region, actual death rates range from 2%-7% (US =5.31%) of those with symptomatic COVID-19 compared to the flu with a 0.1% death rate that are symptomatic.
To put this in perspective:
Flu: 1 in 1,000 in US died in 2018 that were diagnosed and symptomatic
COVID-19: currently, 20 - 70 in 1,000 died that were diagnosed and symptomatic.
US death rate is 20-70 times higher than flu
Global death rate is 68.9 times higher than the US flu death rate of those diagnosed.
SARS: 100 in 1,000 death rate
MERS: 340 in 1,000 death rate
Ebola: 500 in 1,000 die
Given the time to progression of up to 14 days and lack of testing most symptomatic patients, it is unknown if the US death rate will sustain the current 5.31% or approach the 6.89% of world over next few months as we ease social distancing policies. The virus could also mutate to a less deadly form and/or physician use of off-label potential drugs could sustain a lower rate in the US – we will all know together in the next several weeks. We will also find out if warmer weather will slow this virus as the seasonal flu in next few weeks, but indications are this is not the case for COVID-19.