The Good News and the Bad News about COVID

Congratulations, America. You have survived Stage 1 of the Tour de COVID. You pulled together, and learned all kinds of new tricks. How to Zoom. How to order groceries online. How to homeschool kids. And the trickiest of all: how to walk in public with an awareness of your space that requires not burying your face in your phone. You did it!

The nightmare version of Leg 1 only hit certain places like nursing homes and New York City. Most of us have our families intact and only have secondhand stories of people who died. America is collectively having a huge sigh of relief. We’re ready to hit the beach and see old friends again.

I do want to emphasize that there is a lot of good news about COVID. So I’ll try to highlight that before dipping into the bad news.

Good News: New Zealand eradicating COVID means that the island country can return to normal life, complete with rugby games, schools, beach parties, and whatever else Kiwis do for hedonism. But this is even bigger than that. This proves to the rest of the world that you don’t need a miracle cure or vaccine for life to go back to normal. You can beat back COVID entirely with pure and simple public health and testing. Sure, there will continue to be imported cases from travelers who go abroad. But strict quarantine and testing can stamp out imported cases before they spread to the community. In theory, any country, rich or poor, can do this. It sure helps to be an island nation with secure borders. But Rwanda is taking notes.

Bad News: America ain’t New Zealand. Yesterday Arizona had over 1,000 new COVID cases. We managed to blow up our economy, spike unemployment, and we still can’t play baseball.

Science Sidebar: There are two particular features of the SARS-CoV-2 virus that explain why the pathogen is so difficult to control. The first, symptom heterogeneity, is something we’re all familiar with. The just means that some people have zero symptoms and some people die. If you wanted to bioengineer the worst possible pathogen for humanity, you wouldn’t want the virus to kill everyone it infected. That would just be like Ebola: really nasty in the people it infected, but not good at transmitting around the world. You would want it to be stealthier, transmitting silently in large numbers and only killing selectively. That’s COVID.

A feature of the SARS-CoV-2 virus that may be less familiar is transmission heterogeneity. This means that there’s a lot of variability in how many people an infected person actually transmits the virus to. You’ve probably heard about R, the reproduction number that represents how many secondary cases arise from an index case in a population, on average. This number is central to the growth dynamics of an outbreak. But you probably haven’t heard as much about the parameter k, transmission heterogeneity. When R = 2 it doesn’t mean that each person transmits to exactly 2 people. The vast majority of people could transmit to 0-2 people with only rare outliers transmitting to 10-20 or more. High transmission heterogeneity means a lot of superspreading events that introduce a great deal of volatility into the system. It means that lots of virus introductions into a given location won’t transmit at all. But occasionally you’ll get introductions that spread explosively and cause sudden outbreaks. This explains why you see communities have no cases for long periods of time followed by sudden explosive growth. It also explains why it’s hard to predict why the virus takes off explosively in some locations and not at all in others. A lot of it is just random. You can reach false conclusions if you don’t account for transmission heterogeneity. You can look at a community that never closed schools and has few cases and decide that schools aren’t important in transmission. When really it’s a lot of random chance whether a virus introduced into the community takes off or not. You just need to roll the dice enough times.

Good News: You can relax on the disinfectants. No need to wipe down your groceries (I never made my mom do this). Back in March I listened to a well known NYC ER doc advise people to Purell after every touch of a door handle or elevator button. I told Aaron this was nuts.

Bad News: Wiping down tables is far easier than coming up with new systems to minimize human contact and density and move activities outdoors. But restaurants, schools, day cares, gyms, or churches cannot simply make Purelling the hell out of the place the centerpiece of their control strategy.

Good News: I’ll continue to be bullish on vaccine development. I believe we will have a safe, effective vaccine in 2021.

Bad News: Once we make a vaccine, there’s a little problem called distribution. You need to get that vaccine into the arms of people. Millions of people. That requires logistical planning about where vaccine doses should go and when. Because we’re not going to have 300+ million doses all at once. We’re going to need to prioritize what groups get vaccine first. You may think this is obvious. Old people. Healthcare workers. But what about other essential workers on the front lines who put their lives at risk? Firefighters? Police? Grocery store workers? Utility workers? School teachers? Political leaders? And what happens when lobbying and political interests get involved? Should baseball players get vaccine before high-risk workers in meat-packing plants? Lordy…..Make yourself a big bucket of buttery popcorn and watch the food fight unfold. And remember, letting the neglected classes get crushed is just the American way.

Also…..as long as we’re getting the bad news out of the way. When you put a new vaccine in millions of people, some people will get sick shortly after. You can be sure that the stories will make media headlines way before epidemiologists have a chance to figure out whether there’s any connection. Most connections will be bogus (like autism and measles vaccine). But there is still debate over whether the adjuvanted 2009 H1N1 influenza pandemic vaccine caused narcolepsy in some kids in Europe. America is already a vaccine-skeptic country, so my intention is not to fan any of those flames. I and everyone I know will be getting the COVID vaccine. But be prepared for media headlines about vaccines causing disease. But as seen with the H1N1 narcolepsy story, it can be very hard to tell when there is a very small number of cases. Especially when publicity in the media artificially increases clinical diagnoses. Conditions like autism and narcolepsy can go years before being diagnosed, so higher awareness in a community can dramatically accelerate detection rates.

Good News: There has been an incredibly steep learning curve about how to better treat hospitalized COVID patients. At the beginning ER docs faced a novel disease and had very little information. While it’s tragic that there have been over 250,000 patients hospitalized for COVID in the US, at least we’ve used those experiences to learn a great deal about what works and what doesn’t. The debate about whether to treat with hydroxychloroquine was just the tip of the iceberg. We’ve learned a lot about how and when to administer oxygen, including less invasive and risky procedures than intubation. Simple steroids have also been shown to be effective. So if you have an occupation that puts you at high risk for contracting COVID, know that every month that you hold off infection makes a good clinical outcome more likely.

Bad News: This is a really nasty virus. COVID is more than a respiratory disease. It has high tropism, meaning that it can infect the brain, blood, kidneys, etc. The virus destroys the body in so many different ways. And many people who survive will still have severe longterm problems we’re just beginning to grasp.

Good News: Kids are still not getting severe disease. Furthermore, kids are half as likely to get as infected as adults.

Bad News: Kids that do get infected turn out to transmit just as well as adults. Even if kids are half as likely to get infected per exposure, kids typically have larger playgroups and more contacts than adults, so this kind of evens out. Especially when schools and day cares are operating. This means that if you want schools to be open in the fall, you’re going to need to really drive down COVID levels in your community over the summer.

Good News: America has all the ingredients needed to control COVID this summer. We have a coordinated, data-driven national strategy grounded in intensive testing and an ability to rapidly respond to new flare-ups. That includes consistent, transparent messaging with the public and businesses about how to safely, strategically reopen parts of the economy in a controlled, closely-tracked way.

Bad News: I made that up.

Good News: At least it’s true in Vermont.

TL;DR: America believes it has weathered the worst of COVID and is ready to return to normalcy. But the pathogen is not going away any time soon, and a rush to reopen businesses this summer will make it difficult to drive the disease down to levels low enough to reopen schools in the fall.