Sometimes there actually is a monster under the bed

Now that most of the world is officially in strongly-urged or forced lockdown and isolation, it’s time to look forward to the end of this viral pandemic. Thoughts of late spring days in the northern hemisphere when we can all get back to our normal lives, enjoying time with friends and family as these dark days slowly fade from our memories, will keep us sane over these weeks of isolation.

Of course, most of us are under the impression that this will last no more than a few weeks. Our companies told us we were being laid off just for two weeks, right? The governor of Nevada told us the casinos were all closed for just 30 days. Schools told us kids would be returning to school at the end of March, maybe the first week of April. This is all just a fun distraction with the end just around the corner, right?

Don’t count on it.

If you’re wondering why the world seemed to suddenly wake up to the incredible dangers we’re facing and took the dramatic steps we saw implemented globally yesterday, it’s very likely it was because of this report from the Imperial College of Medicine in Great Britain that was published two days ago. It’s twenty pages long and rather dense, so to save most of you the time of reading it, I’m going to summarize some of the most important (and quite terrifying) findings.

This first chart of infection hospitalization and fatality rates at first glance looks somewhat promising. After all, if you add all these numbers up, the actual fatality rate appears to be just under 1% across the board. That would be a miracle if that holds up to be true, as that rate was feared to be double that number just a short time ago. Another good number is the hospitalization rate, which at only 4.4% means it’s at least 2-3 times lower than many feared at first glance. These numbers have both come way down to the new estimation of the rate of infection, which has gone way up, as we’ll see a bit later. The concerning element of this chart though, is the percentage of cases requiring critical care, which averages out to about 30% of all hospitalizations.

Critical care in SARS related illnesses means a trip to the ICU for a date with a ventilator. A stay in the ICU means a longer overall stay in the hospital. In addition, the average fatality rates of those in the ICU is 50%, which is very high, but inordinately weighted toward those over the age of 80. The real worry about the ICU rate is the number of beds and ventilators required, and the critical surge capacity of our hospitals. Remember, the fatality rate of those who need a ventilator and don’t get one will be 100%, or very close to it.

The study estimates an R-naught rate of 2.4, which is incredibly high. This means that each infected person infects almost two-and-a-half others on average, which is significantly higher than most of the viral outbreaks we’ve seen recently. This R₀ rate, would result in an infection rate of approximately 81% of the population, with an estimated 2.2 million deaths in the United States alone, had we decided to take no action, or very limited action in response to Covid-19. These numbers do not take into account all of the additional deaths that would occur due to an overload of the surge capacity of our healthcare system. The study estimated that the peak required ICU admissions would reach more than 30 times the national capacity. That would have resulted in a secondary fatality rate that might have been even higher than the deaths from the virus alone.

Good thing we took serious action, eh?

Now, here’s the problem with taking serious action against the spread of this virus. In order to prevent a secondary outbreak before a vaccine is ready, it’s necessary to establish “herd immunity.” Herd immunity means that people need to get sick and then recover in pretty big numbers in order to make sure that the R₀ rate falls below 1 on the next wave of infections. Any R₀ rate of 1 or below ensures that the coronavirus remains under control and does not become a pandemic. The sooner we implement isolation requirements that control the spread of the virus, the fewer infections we have and the greater the likelihood of a reinfection when restrictions are lifted.

What a fun little circle-jerk game this virus is playing with us!

This chart shows us the effect that various isolation measures will have on the surge capacity of our hospitals, represented by the red line at the very bottom. It’s quite obvious by looking at this that none of these measures on their own are anywhere near effective enough, which means that a combination would be required to avoid overloaded hospitals and huge numbers of secondary deaths from triaging those who need advanced care. The “things that make you go hmmm” moment for me with this chart was the blue shading. This shows the period of time that would be needed for each of these measures just to result in the deadly peaks shown here. More on that later.

Above this chart we see this line: Our projections show that to be able to reduce R to close to 1 or below, a combination of case isolation, social distancing of the entire population and either household quarantine or school and university closure are required (Figure 3, Table 4). Measures are assumed to be in place for a 5-month duration.

The key here, obviously, is reducing R₀ to 1 or below, and they’re basically saying that it’s going to require all of the measures listed to be working and in place at the exact same time. The scary part of this though, is the last line. Measures are assumed to be in place for a 5-month duration. Five-month duration. That blue shading represents five months under these conditions. Not two weeks, like we were told at first. Not 30 days, or 60 days like a few are saying. Five months. Through the summer. We can say that we began this around March 15^th. That means we can come out of it on August 15^th. How many of you think we can maintain this for five months? No frickin’ chance.

If we do somehow maintain these conditions for five months, notice the green and tan lines in Figure A stay right around the red Surge line. This basically means we don’t overload the ICU. We don’t run out of ventilators and begin triaging the worst cases and sending them home to die a very miserable death. This is really important, but again, it’s going to take five months of combined strategies and at home isolation.

Also, notice those spikes of both the green and brown lines in late November / early December. What this means is that we’re going to see another spike of this disease next fall. This is very likely going to require yet another stretch of isolation. Interestingly, the green line, which represents what we can expect if we implement the easiest of the measures, school closure, social distancing, and case isolation, will give us a much higher spike in critical cases than if we implement household quarantine without school closure. That means that it may be correct to allow the kids to go back to school in the fall while the adults all stay quarantined, as counter-productive as that may seem. Oh, and by the way, if you thought your kids were heading back to school this spring…spoiler alert—they’re not.

Short of a complete lockdown, which is the absolute best case scenario for stopping that first spike (although that will result in a much more difficult secondary infection—more on this in a bit) applying all four isolation measures is the most important way to minimize the impact to the healthcare system. The problem — again — is that they need to be held in place for a minimum of three months, five months ideally, and that seems absolutely impossible, at least here in the United States.

***Just as an FYI if you’re looking closely at these charts, all the numbers represent expectations for the UK, not for the US, however, our medical and health care ratios mimic each other with the US at a 5x rate. So, basically multiply every number you see by five, and you’ll get the expected numbers for the US with the lines remaining identical.***

This chart is fairly self-explanatory, so I won’t go over it in detail. The R₀ number on the left represents the most likely infection rates they could estimate with the data available. “On Trigger” is the number of critical ICU cases that trigger the isolation efforts. Obviously, the earlier we trigger those the better. “Do nothing” is number of deaths if we take no isolation steps. PC=school and university closure, CI=home isolation of cases, HQ=household quarantine, SD=social distancing of the entire population, SDOL70=social distancing of those over 70 years for 4 months (a month more than other interventions). The percentages represent the percentage decline in the death rate from the “Do Nothing” category. Again, these number are for the UK, so multiply them all by FIVE to get the numbers for the U.S.

Once these interventions are ended, infections begin to rise again, as we saw in the new curves on the previous graph, resulting in a predicted peak epidemic in late November. What’s really interesting though, is that the more successful a strategy is at temporary suppression through the isolation efforts, the larger the later epidemic is predicted to be because of what they call “herd immunity.”

When we isolate everyone and fewer people get sick, fewer people develop immunity to it. Even in a best case scenario, the virus doesn’t disappear altogether once we have it under control. It’s still out there in the wild, waiting to be picked up again, and that’s why we’re going to see another large spike in cases in the late fall. There’s no avoiding it, short of an immunization being developed, and the better we are at controlling the virus now, the worse that next outbreak will be. The more people who get sick now, the more will have immunity later. The key is to not overload the health system and the ICU capacity while allowing the maximum number of people to get sick right now. It’s an incredibly tricky balancing act.

This shows the number of deaths and ICU bed occupation we can expect to see with the various interventions. Let’s take a low-medium R₀ of 2.2, so the second block of cells. ***Again, remember that for the U.S. we need to multiply these numbers by five because this is for the UK.***

I feel like the most accurate number for the on-trigger death toll is about 200, which represents 1000 deaths here in the U.S. Although we’re currently at only 155 deaths, we’ll be at 1000 in a little more than a week most likely, and, I don’t know about you, but I’ve seen very few people actually taking this seriously. In fact, today I saw video from spring breakers partying it up in Miami, saw pictures of people in bars, restaurants, airports, and coffee shops, and saw lots of traffic: street, pedestrian, and aviation, despite so many desperate pleas from authorities to stay home and avoid going out as much as possible. So many people have adapted a blasé attitude toward this, that I feel quite comfortable using that number, and it wouldn’t be much of a stretch to use the bottom number of 400, representing 2000 U.S. deaths, or even a number that’s completely off the chart, quite honestly. But we’ll be conservative.

Using the 200 deaths number and extrapolating through the chart by multiplying by 5, we see that if we did nothing, we’d expect 2.1 million U.S. deaths. This is in the next five months, by the way, and doesn’t even take into account all the added deaths from ICU triage overruns, and the spike next fall (which, in defense of “do nothing,” would be significantly lower, possibly even compatible with an R₀ under 1) which would all result in a number at least double that. Now, looking to the right, you see that the most effective step is to take all four isolation steps (PC=school and university closure, CI=home isolation of cases, HQ=household quarantine, SD=social distancing of the entire population, SDOL70=social distancing of those over 70 years for 4 months) Of course, let’s be honest, this here is the good old U.S. of A., and there’s no chance we’re doing HOUSEHOLD QUARANTINE for three months, so let’s move one box to the left where we see an expected fatality rate of 30,000 times 5 = 150,000.

That’s 150k deaths if we keep up what we’re now doing, and if the idiots stop doing Jaeger bombs in Miami, and if the businesses all close down, and if people stop hugging each other, shaking hands, working in close proximity and going out to eat. Oh, and if we keep all that up for the next three months. So, yeah, basically we’re screwed. I would guess we can easily expect double that death number.

If the R₀ rate is higher, we’re looking at 350k deaths, and double that is 700k deaths, plus, that number will overload our ICU capacity so we can probably call it a million flat. And, quite honestly, I think this is being incredibly conservative based on the behaviors I’ve seen all over the internet from the multitude of people who just don’t give a flying fuck about what’s happening. I’m talking mostly to you millennials, though I know the percentage of you who made it this far into this read is as close to zero as (insert name of your favorite IG star here)’s intelligence. To be fair, it’s not just the millennials. So many Americans just don’t get what’s happening here, and, I don’t know what it will take to wake them up.

Every sports league, done. Las Vegas shut down completely. Borders basically closed. Domestic flights mostly shut down by the end of next week. (Another prediction, there’s no sign of this yet, but if you’ve read my previous blogs have I been wrong yet?) When will people start to realize what’s happening here?

I’m afraid it won’t be until we reach 100k deaths in the U.S. I’m afraid that’s when it will finally start to sink in.

Either way, we’re in this situation for at least another three months, possibly as long as five months. And then, just when we think we’re out of it, we’re going to get hit with another wave in November. There’s some hope there will be a vaccine by then, but I’m not counting on it. There’s probably another blog in here to explore a scenario where we rush a vaccine to market and get to experience all the angst with regard to the incredible dangers being taken by skipping animal trials and moving right into the human trial phase, which, astoundingly, is what seems to be happening, from what I’ve read. I’m not sure even I want to explore the possible nightmarish scenarios behind that decision. After all, I understand that the monster under the bed is now real. I hear him stretching and stirring, his claws ticking on the hardwood floor, and I know he’s about to unleash his full wrath.

I’m not sure I really want to get out of bed to peek at the noises I’m now starting to hear coming from the closet.

*BTW, here’s that full report in case any of you want to read it. I’d love to know if I misinterpreted or misstated anything in my synopsis. Thanks! https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf