There have been over 20 major disease events in recorded history. Each lasted between less than a year to more than a decade, averaging 2-4 years. Those pandemics followed several predictable paths that provide us insight into when the pandemic will end.
At the time of this writing, an estimated 165,000 Americans have died from COVID-19. This total Includes those who were diagnosed with COVID-19 at time of death and excess deaths or deaths above historical averages, but were not diagnosed with COVID-19 prior to death.
The United States Federal Government provided guidelines for states to safely reopen, based on measures related to bending the curve, testing capability, hospital capacity, and trace & isolate efforts. Although only Illinois has met all of the criteria, every state has begun reopening.
Sweden is the most prominent country to disregard recommendations and proceed without significant closures or enforced social distancing or mandated mask policies. The results give Sweden one of the highest mortality rates per capita, exceeding the US by 40%, and with a rate six to twelve times that of their neighboring countries. Sweden’s economy is expected to contract 4.5% this year while consumer spending has already decreased by 25%. The US would likely face similar outcomes if it decides to follow a similar strategy.
Failure Isn’t An Option
The US death rate has dropped 1% since the start of the pandemic, which has given some a false sense of security. This reduction has been attributed to several causes with the greatest being that the average age of COVID-19 patients has decreased substantially. Higher risk patients have chosen to maintain self quarantine regardless of reopenings, while younger Americans flock to bars and restaurants as soon as they open. The second reason is the many low income and uninsured people aren’t getting tested or proper medical care. These people, the largest demographic affected, are dying at home in record numbers. Those deaths only show up in the excess death count and not the official COVID-19 fatality rate.
The fact remains that the higher the peak rises, the more people will die.
Fatality Rate and Rate of Infection
Although the case fatality rate is dependent on multiple variables, the only ones we can control are wearing masks, social distancing and maintaining sufficient medical capacity. The lowest case fatality rate measured is 1.9% in South Korea, and the worst is 10% in Spain. In New York the case fatality rate is 8%. In Michigan it is 9.6%.
The higher the rate of infection, the higher the case mortality, which then spills over and increases the all-cause mortality rate, as medical care is shifted from preventable diseases to COVID-19 treatment, and people avoid the hospital out of fear of infection.
If hospital capacity becomes overwhelmed the total death rate will spike to unconscionable levels in both COVID-19 cases and all cause mortality.
Path 1: Smother the Disease
The SARS epidemic lasted only six months and was extinguished primarily due to social health policies including near universal mask wearing and hygiene practices. The virus died off because it wasn’t able to infect any more people.
New Zealand is the most successful in deploying a similar strategy and has had no new community spread cases in weeks. This success was made possible through a combination of short term lockdowns, mask and hygiene standards, robust contact tracing, and mandatory quarantines at government facilities for anyone entering the country.
While this path is possible for the United States, significant changes in public policy would have to occur, which seem unlikely at this point.
Path 2: Herd Immunity and Antibody testing
The Flu pandemic of 1917-1919 surged during the cold months for 3 years, with the worst wave hitting in 1918. After claiming 500,000-850,000 American lives, enough people had built up immunity and the disease wasn’t able to spread and died off.
If infections of SARS-CoV-2 give one full or partial immunity to future infections, we still don’t know what level of the population would have to be exposed to obtain herd immunity status. For measles it’s 91%, for H1N1 it’s 40%, current estimates put COVID-19 at 60% to 80%, but nothing is certain.
Antibody testing allows us to test to determine who has COVID-19 and who has had COVID-19. Understanding who had asymptomatic COVID-19 will give us a better understanding of how far the disease has spread and improve our capacity to accurately model the disease progression. Without that information, we are flying blind.
Identifying asymptomatic cases are critical to our understanding and containment of the disease. Widespread testing in Iceland revealed 50% of cases are asymptomatic, while aboard the USS Theodore Roosevelt, asymptomatic cases were found to be up to 60%.
Wuhan, China is currently rolling out wide-spread antibody testing. The initial results are discouraging, with only 2-3% of people testing positive for antibodies. Spain completed similar testing and found 5% of people possessed antibodies. These results suggest that we have a long way to go to achieve herd immunity. Antibody testing in the US painted a rosier picture so far, but their flawed methodology has made the results unreliable.
Initial studies of COVID-19 antibodies show that potential immunity may last for as little as 2-3 months. That amount of time isn’t long enough to establish widespread protection. Some scientists think longer term immunity may be possible through T-cells. But, COVID-19 targets and kills T-cells, potentially negating that advantage. So much remains unknown about the way natural immunity reacts to this virus which makes this strategy highly risky and likely to produce mass casualties in the process.
Path 3: Treatment Protocol
From 1981 to 1994 AIDS ravaged across America, even becoming the leading cause of death for all American’s age 25-44 at its peak. In 1995, Highly Active AntiRetroviral Therapy (HAART) was introduced that significantly diminished the harms of the HIV virus. Today HIV is not considered the death sentence it once was. The development of treatment protocols can contain the spread of a disease along with the harms it causes to society.
While many treatment options are available now for a compassionate use basis, we still lack data to determine which ones are effective. Historically, drugs making it through clinical trials have a 20% success rate. We will start to see data over the next few months, but wide scale adoption of a treatment protocol is unlikely until the end of summer.
Remdesivir has shown the most initial promise, but the medication is expensive, in short supply, and limited by production capacity. Another drug, Dexamethasone, a widely available and cheap steroid, has shown promise in reducing the fatality rate in the most severe cases. But Dexamethasone doesn’t shorten the disease duration period, which still leaves risks to healthcare capacity.
A robust treatment protocol that saves lives and prevents hospitals from becoming overwhelmed might not be seen until 2021.
Path 4: Vaccine
Measles and Polio are both diseases on the brink of eradication due to the development of vaccines. And, the yearly flu shot attempts to protect the most vulnerable populations from the worst harms of influenza.
At present, there are over 62 teams currently pursuing a vaccine. Typical vaccine development takes at least 5-7 years. The current record is four years for the mumps vaccine. By hyper accelerating the development schedule, the earliest a vaccine could become publicly available is after a year of development in early 2021. Drug makers are preparing to produce as much as 2 Billion doses by the end of 2021.
Vaccine development faces many challenges. There is no vaccine for any other type of coronavirus. Less than 10 percent of vaccines make it through clinical trials. And, rushing the process and missing critical safeguards can lead to a vaccine that enhances the disease instead of diminishing it. Other diseases like HIV have had a vaccine in development for over 40 years and still haven’t been successful.
Currently three potential vaccines are in stage 3 trials. These vaccines are based on innovative technologies that have yet to be successfully deployed. It is too early to tell if these vaccines will make it through all phases of testing or even how long the protection will last if they do. If a vaccine requires more than one dose, that would substantially increase the amount of doses needed to create herd immunity.
A Return to Normalcy
These 4 paths could be combined to bring about a post pandemic return to normalcy be it in 2021, 2022, or even 2023.
COVID-19 is here to stay
SARS-CoV-2, the virus that causes COVID-19, is in the coronavirus family of diseases. There are 6 other famous coronaviruses: SARS and MERS, which were limited in spread and died out, and 4 others which cause a form of the common cold. There is a high probability that you’ve been infected with one of those 4 coronaviruses. Those 4 are ever present in the environment. They are considered endemic, surging seasonally and will never fully go away. Scientists believe that SARS-CoV-2 will eventually become endemic, like the flu or the common cold. Treatment options and vaccine immunity will make it just as treatable, yet still as serious as those diseases.
What To Do Now
What makes COVID-19 different from other viruses is:
- There are a large number of asymptomatic carriers that hide the true distribution of the disease and could be driving transmission to others.
- Natural immunity appears to be short-lived, making it unlikely the disease will fade away on its own like the flu pandemic of 1918.
- The disease spread is highly influenced by a few individuals who become super spreaders. Super spreaders can infect 100s to 1000s of people while not getting super sick. They are often the people who show few symptoms and who go about their day uninhibited. About 10% of COVID-19 infections have caused around 80% of new infections.
Just because the country is pushing to reopen doesn’t mean we are returning to normal. The national strategic response has centered around preserving national healthcare systems, not reducing the number of active cases to zero. If we do not want to return to lock downs, then safety standards must be observed until a longer term solution is found.
Businesses will need to adapt to these circumstances for the foreseeable future and make the necessary structural, financial and procedural changes with a long-term view: This is the new normal for 2020 and beyond.
Individuals should deploy the following strategies to stay safe and prevent the spread of the disease to others:
- Since asymptomatic spreaders are responsible for a lot of infections, yet do not show significant symptoms, you should act like everyone has the disease until proven otherwise, including yourself.
- Minimize contact with others, maintain six feet apart, wear a mask when entering any public or enclosed space, don’t touch your face, and wash hands frequently.
- If you came into contact with someone who at any point tested positive, go get tested, even if you don’t show symptoms.
- If you experience any of the following symptoms, then go get tested:
- Fever or chills
- Shortness of breath or difficulty breathing
- Muscle or body aches
- Sore throat
- Congestion or runny nose
Companies should implement safety protocols and follow their state and local requirements and recommendations.The following strategies should be considered to keep employees healthy, maintain operations, and minimize liability:
- Create a workplace environment where all individual safety standards can be observed. If necessary, reduce the number of people who are in the office at one time. Slowing production to observe safety standards will result in a better outcome than having to shut down completely due to an outbreak.
- On a daily basis, have a medical professional or a properly trained and protected staff member check employee temperatures and survey for symptoms. Take special care to observe all HIPPA requirements and protect employee confidentiality. However, be cautious about creating health records that could trigger record keeping requirements that last up to 30 years after the termination of employment.
- Adopt sick leave policies so employees are properly incentivized to take time off when sick. Sick leave policies that are not aligned with employees’ needs will not only cause the disease to spread in your workplace but cause considerable reputational harm to your brand that could last decades. The Families First Coronavirus Response Act (FFCRA) establishes sick leave requirements and tax credits for eligible US companies through December 2020.
We’re at the bottom of the 3rd inning of a game that could end up becoming a double header if we’re not careful. Letting our guards down too soon will cause more people to get sick, which will make the pandemic harder to contain, which will in turn draw out the recovery, and will continue to hurt everyone in the process. Stay safe, stay healthy.