COVID: new projections with loosened social isolation

The New York Times just published new mathematical models that suggest the Covid-19 cases and deaths will rise at an accelerated rate after the current easing of social distancing measures in many states (see https://www.nytimes.com/2020/05/04/us/coronavirus-live-updates.html#link-7b42d0f5 )

Details:

-- the Trump administration forecast about 200,000 new cases each day by the end of the month (up from 25,000 daily currently) with 3000 deaths on June 1 (practically double the current number of 1750)

    -- Trump himself said 2 days ago that the deaths in the US could reach 100,000, twice as many as he said 2 weeks ago, and still considerably less than predicted by his own administration

-- the Institute for Health Metrics at the University of Washington ((frequently cited by the White House) is now projecting 134,475 deaths in the US through early August (ranging from 95,092-242,890), reflecting the easing of social distancing and rising mobility in most US states by May 11, as well as our increased understanding of viral transmission models. Of note, their forecast on April 17 had been 60,308 deaths by August 4. In particular their new-model forecasted deaths , by August 4:

    -- Texas: 3632 (1470-10,721)

    -- Georgia: 4913 (2013-12,125

    -- New York: 32,132 (29,248-37,136)

-- the researchers also predict increases in European cases, though these are dramatically less than in the US:

    -- UK: 40,555 deaths (up from 27,100), with a range of 12,657 to 74,539

    -- Italy: 31,458 (up from 27,777), with a range of 29,605 to 34,969

    -- France: 28,859 (up from 25,096), with a range of 25,280-38,798

    -- Spain: 27,727 (up from 25,231), with a range of 25,720-32,130

    -- Germany: 8543 (up from 6922), with a range of 7006-12,150

--another public model often cited by the government also revised their estimates to more than double what it was last month (see https://www.nytimes.com/interactive/2020/04/22/upshot/coronavirus-models.html ). 

    --they estimated total deaths being 60-100,000 though May 23, based on the current isolation measures, but do not extend projections beyond 2 months

-- some states are easing restrictions even though their Covid cases are still increasing (i.e. Indiana, Kansas, and Nebraska) and others have partly reopened while cases are increasing (e.g. Iowa, Minnesota, Tennessee, and Texas).

-- in terms of rural areas: food processing facilities and prisons have some of the country’s largest Covid-19 clusters, with per-capita cases surpassing New York City

    --for a very thoughtful article on the Covid-19 issues in incarcerated populations and plannng/decarceration, see https://www.healthaffairs.org/do/10.1377/hblog20200406.581615/full/ (where one my previous fantastic residents, Haiyan Ramirez Batlle, is the second author)

Commentary:

-- There is a lot of talk about flattening the curve, or seeing a plateau in the number of new cases or deaths.  i am very concerned that people (including us clinicians) may extrapolate that to meaning that we are finally stanching the epidemic

    -- BUT, it is important to realize that that plateau is still a high number of cases in many areas and will take a long time to decrease. The NYT Times has a graph of cases by state, noting that in most states where new cases are decreasing, there still are huge numbers of daily cases: see https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html (with the necessary caveat: "but a lack of widespread testing may mean that cases are being undercounted")

    -- As a yardstick, and as mentioned in prior blogs, Wuhan has only recently reached the point of zero cases of Covid-19 in the hospital. And that was after 5 to 6 months of very aggressive virus containment strategies, including aggressive testing of contacts, enforced isolation of patients, restriction of people being outside, closing down transportation to and from the area, aggressive identification and hospitalization of infected people, etc (see http://gmodestmedblogs.blogspot.com/2020/04/covid-superiority-of-contact-tracing.html ). 

    -- Loosening restrictions will also likely increase the transportation of the virus from states with higher incidence to states with lower incidence (i.e. flattening the differential curve between states)

-- It is important, of course, to realize the huge economic and personal burden of our current isolation: many people have lost jobs and essential income, to the point where some people would rather work in a situation that might well expose them to the virus in order to survive. Unfortunately, in the US, we do not have a significant social safety net for people. In several countries in Europe, for example, people are paid 80 to 90% of their wages during the pandemic.

-- and, there is the "quarantine fatigue" effect, where many people (i suspect largely of the younger age) just want this all to end and get back to their lives. but, again, we have been doing our version of virus spread mitigation for less than 2 months, a far cry from the more intense one done in China for many months that actually worked

--one concern with these projections is that we still have very limited data from the US. some of these models extrapolated from the viral infection curves in other countries, but in the US there is no consistent approach across different states. and we really do not have much information about the levels of asymptomatic cases (who still have transmissable virus), or even those with mild symptoms similar to other viral upper respirtatory tract infections. so, we really don't even know the true infectivity rates or the death rates from infection, or even the potential for currently infected individuals to be reinfected in future months with a later wave of the virus (we do know that many who had been infected do not mount much of a neutralizing antibody response, and they may well be susceptible to another infection. all to-be-determined). i imagine that the very wide ranges of the projections noted above for the US reflect the huge gaps in information and uncertainties associated with rolling out isolation-easing

-- And, of course, the expected response of Trump is to control the information: the White House has barred members of of its own coronavirus task force and their aides from appearing before Congress without the express approval of the White House Chief of Staff; and officials from the Department of State, Health and Human Services, and Homeland Security are restricted to appearing at no more than 4 hearings department-wide for the duration of May.  

 

So, we’re traveling on a very dangerous road. Decreasing social isolation will likely improve the local economies in the short-term and make many people happy (and perhaps one president more re-electable), but also create the groundwork for accelerated virus spread nationally, and 2^nd and 3^rd peaks of viral activity in areas that have already been hit hard. One concern cited by the CDC director Robert Redfield is that there may well be a Covid-19 peak again coinciding with the flu season, which might put an ”unimaginable strain on the healthcare system”.

it is so stressful to know that, yet again, we are moving in a direction that will really hurt lots and lots of people. it was really not hard to predict that the US was a setup for where we are now, the number 1 country (by far) in Covid-19 cases and deaths, despite (intentionally) ignorant remarks from our "leaders". and, here we are again. this raises perhaps one of the best quotes from Einstein: "the definition of insanity is doing the same thing over and over again, but expecting different results"

geoff

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