In case the COVID epidemic has piqued your interest in the wild world of viruses, there are some wonderful books that manage to pack scientific detail about viruses, emerging pathogens, and the threat of global pandemics into vivid narratives aimed for a lay audience. Here are 5 non-fiction books I recommend. Excellent for bored teenagers.
I apologize for the three-week hiatus in the COVID blog. A few Saturdays ago a horse and I had a little disagreement about whether I or not I should be on its back. The horse won. The Suburban Hospital ER was empty except for a few COVID cases, and scans showed that I had experienced a concussion but nothing life-threatening. It was a strange twist of fate that after preparing my entire career for something like COVID, I was suddenly in a brain fog and incapable of viewing screens or even following the COVID situation by radio. For all of you moaning about social distancing, try doing it for a week plus without the distraction of work, Netflix, or cat memes.
So after a three-week semi-dream state I’ve woken up to a brave new world. Some things have stayed the same, including the curious age structure that is mostly sparing children from severe disease. And of course the absence of toilet paper on any store shelves. But in my three-week haze America raced to the top of the global COVID case count. Part of this is increased testing, which we finally seem to have gotten up and running after a botched start. However, I will continually emphasize that the true epidemic is far worse than the case counts and death tallies suggest. We are still massively undercounting cases due to lack of testing. And even the reported death toll is just a fraction of the true number of deaths (which will be statistically calculated, within a certain degree of uncertainty, only after the pandemic is over).
Americans also seem to have all overnight become experts in viral epidemiology. Who imagined a day when droplet transmission and reproductive number would be trending on Twitter? There are some consequences to the proliferation of armchair epidemiologists. The internet has become a cesspool of misinformation. At this moment Americans desperately need reliable information. To know how to stay safe. And to know that they’re tanking their economy for a good reason.
One of the problems is that it can be difficult to evaluate the quality of information, especially on social media. A source of confusion is figuring out who is really an expert. A professor from an eminent US university with a fancy title (e.g., laureate) seems like they should know what they’re talking about. So should a top infectious disease doctor. I can perfectly understand that when COVID is taking over people’s lives there is an irresistible urge for anyone with a loose connection to the biomedical field to weigh in on aspects of COVID. Even in areas far beyond their specific area of expertise. You just make some reasonable assumptions, plug in the little numbers (death rates, attack rates, our favorite reproductive rates), and voila! Anyone can make a pretty graph.
I wish it were so easy to make a good COVID model. I wish we had really good underlying data drawn from intensive testing so we could nail down even simple parameters like rates of mild and asymptomatic infection. Across all age groups so we could know whether children were important in transmission. I wish we had a finely-tuned model that could be more prescriptive about the kinds and intensity of social distancing is needed and for how long. Right now, in the absence of good data, we’re using social distancing as a bludgeon rather than a scalpel. It’s like an elimination diet where you just stop eating everything — gluten, eggs, nuts, dairy — because you don’t know the specific culprit yet.
At this time, we have enough information to know that the situation will be dire if we don’t do anything. That’s not up for debate. But we don’t have a more detailed model that could fine-tune our approach to social distancing. At least not at this late stage in the epidemic (more targeted contact tracing was an option early when the virus was just entering the US but at this stage could not be done without a massively higher intensity of testing). The current unavailability of a good model that can answer our most pressing questions is not because US epidemiologists aren’t any good. There is a relatively small and tight-knit community of experts in the field of mathematical modeling of emerging pathogens. The community has grown over the last decade, as H5N1, Ebola, Zika, and other emerging infectious diseases have increased funding and scientific interest. However, neither H5N1, Ebola, nor Zika every truly invaded America, leading us to become complacent, and major funding networks across the US government for infectious disease modeling have lapsed.
So the list of people who have any business building models to predict the trajectory of COVID-19 would fit no more than a single page. What makes building a COVID model so difficult is how many uncertainties there are, not just about the virus but also human behavior. It doesn’t matter if you’re a professor of epidemiology at an esteemed university or one of the top infectious disease doctors, it takes years of specific study of modeling pathogen dynamics needed to accurately account for these kinds of uncertainties.
Just, to be clear, I am not a modeler. I am an evolutionary biologist who happens to work closely with mathematical modelers. I have great respect for how difficult it is to make a good COVID model. There are enormous gaps in data and information needed to parameterize it. And the parameters are constantly changing as humans modify their behavior. And being a good modeler is a thankless job. Either everyone ignores your model and you fail to help anyone at all. Or politicians take necessary actions and avert a full-scale epidemic, effectively making all your original projections wrong. Which is of course a good thing. But it leaves people with the impression that modelers chronically over-hype.
My area of expertise is how viruses evolve. I’m the person who knocks down the rumors that there are genetically different strains of COVID circulating that cause different severity of disease. Or that the virus will mutate over time to become less lethal and more like a typical cold virus. (It’s quite the reverse. Over the next year or so humans are the ones who will be changing, developing natural or vaccine-induced immunity that makes re-infection less severe. Over the next decade, rather than mutating to become less severe, coronaviruses, like influenza viruses, may continue to evolve to evade human immune responses and cause recurring seasonal epidemics.)
Okay, I’m still limited in my daily allowed screen time. But I want to clear about one final thing that seems to be tripping people up: masks. I am absolutely heartened that so many Americans are willing to don masks to help #flattenthecurve. While it’s been part of Asian culture for a long time to wear a mask when you’re sick, in the West masks are only for doctors, nurses, and Halloween. So, should we imitate the Asians? First off, there is currently a severe shortage of medical-grade masks for doctors and nurses, so if you have a commercially made mask you should donate it instead of wearing it. Even if you’re a risk group. Because the mask cannot protect you, it can only reduce the likelihood of you infecting someone else. Second, if you’re considering making a homemade mask, there’s been a line of thinking that this should be encouraged because keeping your mouth from spewing droplets and infecting other people, and at worst it couldn’t do any harm. But I do think people should be aware of potential harm. An important part of the fight against COVID is training people not to touch their faces. So just be aware that masks that are itchy, uncomfortable, or ill-fitting could actually draw the hand the face, especially for people who aren’t used to wearing them. Or subconsciously give people a false sense of security that emboldened them to do activities they otherwise wouldn’t do without a mask. So it’s not a scientific question, but a human behavior question. But if you’re in a position where you simply can’t follow social distancing at all times (e.g., an essential worker who needs to ride the subway), a mask may be appropriate for a limited time period of commuting. But just keep in mind that the mask is not protecting you.
Hmm, I wanted to finish on a more positive note. I’m going to stretch my screen time a little further to mention something people should do that I don’t think has received as much attention as it deserves. Certainly not compared to masks….. Pre-symptomatic transmission can occur in the days before a person’s first signs of infection (fever, cough, shortness of breath). So if you get a positive test result for COVID, right away you need to inform any people that you had close contact with in the days prior, even before the onset of symptoms, so those people can self-isolate. You should also consider informing people who regularly share surfaces with you know, for example residents in your apartment building. The key is to inform people right away – not days or weeks later.
Taking this another step further, I would even encourage people to let contacts know before you get a test result, as soon as you have been declared a suspected COVID case by your doctor based on symptoms. Many people are still not getting tested, either because they have a mild case or because tests in their area are still unavailable. I understand the desire not to make people unnecessarily anxious, but personally I would rather know if a contact of mine was a suspected COVID case, so I could decide for myself how to act on the information. You could decide to entirely self-isolate if you live with people in risk groups. Or simply postpone going to the grocery store for a period of time.
Most of us are social distancing and hopefully won’t have many contacts. But there are essential workers, whether working in hospitals, grocery stores, or the government, who are still reporting to work, which is why transmission is still occurring. Recognizing the risk for pre-symptomatic transmission and rapidly sharing information about early symptoms and test results with contacts could be a simple, relatively non-draconian way we empower each other to make informed decisions to momentarily intensify our social distancing and potentially break onward transmission of secondary cases.
- American is experiencing a catastrophic disease event unlike anything we’ve experienced since 1918. The virus is deadly and transmissible.
- Other countries in Asia have demonstrated that an early, aggressive campaign of intensive testing, targeted isolation and contact tracing, and social distancing can dramatically reduce COVID transmission. But America missed that early intervention window and we are now the global epicenter. Ahead is a long period of economic hardship coupled with sickness and death.
- The good news? This is not the new normal. Eventually people will gain immunity, either through natural infection or vaccination. This time next year I am cheerfully optimistic we will be enjoying spring baseball again.
Question for next time: what are the most likely scenarios for the rest of the year?
Across the world, people are coming up with great ideas for how to deal with the COVID emergency. I’ll keep a running list in case others want to copy.
Free COVID testing (including emergency room visit), regardless of health insurance (Fed)
Paid sick leave (Fed)
Immune Corps! Enlisting people who have recovered from COVID and are immune to serve on the front lines of the response for people who are sick or in need (I made this up)
Deeper into the Science
Week 11 (March 9-15)
Do I have COVID?
The most tell-tale signs of a COVID infection are:
-Shortness of breath
More details on symptoms here.
A snuffy/runny nose is a sign that you probably have just a regular respiratory infection.
What do I do now?
If you are severely ill, go to the hospital. If you think you can rest at home, call your doctor. Your doctor will probably tell you just to stay home, hydrate, and self-isolate for 14 days. There are no treatments available at this time. This is a virus, not bacteria, so antibiotics are not helpful.
Should I try to get tested?
There are many advantages to knowing if you’re positive or negative for COVID. You can inform people you had prior contact with, since there does seem to be transmission in conjunction with the very first mild symptoms.
When you recover from COVID, you will have immunity for at least the near term. When all hell breaks loose, it would be highly useful to have a cadre of people who know they are immune who could be on the front lines to serve vital roles in the community. For example:
(a) Delivering groceries and essentials to older people at home
(b) Interacting with patients arriving for COVID testing at drive-through clinics
That said, there is a severe shortage of testing capacity for COVID. Most people are being told to not even try.
Week 11 (March 9-15)
There’s a simple reason people can’t decide whether they should be scared out of their wits or shrugging off COVID. It’s because human brains are not good at thinking at abstract population levels. Even doctors’ brains. But you cannot understand the current COVID situation if you don’t have a simple understanding of contact networks and population-level risk. So I’m going to give it a try:
Why you will be scared. COVID is frightening at a population level. At some point, in the upcoming year, someone you know personally is going to die of COVID.
This is because:
In a likely scenario, around 40% of the population will be infected. So if you know 1,000 people, 400 will get the virus.
Maybe half will show symptoms (200 people). Of those, 0.5-1% are estimated to die (1-2 people).
Social networks are complex and variable. You might not have 1,000 close friends, but if you have a couple hundred friends on Facebook, and know many of their friends and family members, plus people you went to school with, people your kids go to school with, and their parents….well, pretty soon your contact network starts to grow exponentially and a thousand is probably a pretty low-ball number.
Why you should not be panicked. The natural instinct is to panic when you hear about people you know getting severely ill and dying. But no matter what happens around you, you must remember that the circle of people you know is probably larger than you realize, and your personal risk is still very low if you are a young, healthy adult or child. Even if you get infected, you have a very slim chance of severe illness.
In the near term, what this means is that your decision to limit your social contacts over the next weeks and months is not so much for your personal health, or that of your children, but for your community and your circle of contacts, especially those at high risk.
That’s why it makes strong mathematical sense to upend your life in many ways, to protect your larger community, but not to panic, recognizing that your personal health is probably not at great risk.
Also, expect that there will absolutely be news reports about children and young people getting severely ill and dying. If large enough numbers of them get infected, there will inevitably be a small number that have poor outcomes. But these news reports do not change the fact that you are low risk.
Week 11 (March 9-15)
What a difference a night makes. Tom Hanks has COVID. The NBA and MLB canceled games. It’s going to suddenly become a whole lot easier for mayors to close schools and cancel senior bingo games. Most Americans now recognize that COVID is going to have a major impact on their daily lives. At this time, our goal is that no American city ever looks like Wuhan. Accomplishing that will require collective action and changes to how we socialize and work over a period of weeks or months. Certain economies will be hit very hard. But here are a couple thoughts to help you sleep at night:
- Our children are safe. For unknown reasons, children, teenagers, and young adults are not getting severely ill from COVID. During past influenza pandemics, deaths were concentrated in children and young adults. Young people with underlying conditions are still at risk. But it should help us all sleep better to know that most children do not appear to be at risk for severe disease.
- Tony Fauci. The director of the NIH infectious disease branch is possibly the most revered government official in the country. Serving since 1984, he has guided 5 US presidents on infectious disease threats — HIV/AIDS, SARS, Ebola. We are currently in a leadership vacuum. But having a high-level figure with impeccable scientific credibility who is deeply respected by both Republicans and Democrats in congress should help us sleep at night.
- Tom Hanks probably won’t die. We don’t know the precise fatality rate because our knowledge of mild cases is so low. But we do know that death rates get higher as you get older. At age 63, Hanks is in a higher risk group. The risk of death in the 60-69 age group is 3-4 fold higher than the 50-59 age group. But it’s still probably only a bit higher than 1 out of 100. Tom Hanks was already an American hero. But it’s possible that his decision to report his infection will save Americans lives by getting everyone to finally take this seriously.
Week 11 (March 9-15)
Summary: COVID is more widespread than the numbers suggest. Waiting until you already have cases in your community before canceling large events will make your epidemic more intense and difficult to control. When you start flooding hospitals with sick people is when people really start dying.
(a) 𝐖𝐞 𝐡𝐚𝐯𝐞 𝐧𝐨 𝐜𝐥𝐮𝐞 𝐡𝐨𝐰 𝐦𝐚𝐧𝐲 𝐀𝐦𝐞𝐫𝐢𝐜𝐚𝐧𝐬 𝐚𝐫𝐞 𝐢𝐧𝐟𝐞𝐜𝐭𝐞𝐝 𝐰𝐢𝐭𝐡 𝐂𝐎𝐕𝐈𝐃. We are still woefully behind in testing for COVID. As of March 9, the UK has tested 18,000 people more than the US (26k vs 8k). That’s 15x more at a population level (per million citizens). Of 18 countries, the only ones the US ranks ahead of in testing are Vietnam and Turkey. We are driving blind. Individuals can’t make decisions about holding or attending events. Local leaders can’t make decisions about canceling schools. At these testing rates, by the time the virus is detected in a community, it’s probably already widespread and will be very difficult to stop.
(b) 𝐅𝐥𝐚𝐭𝐭𝐞𝐧 𝐭𝐡𝐞 𝐜𝐮𝐫𝐯𝐞. We’re not going to be able to stop COVID from transmitting. And if you start to run the numbers (say, 40% attack rate, and 10-20% hospitalized) and take inventory of the number of hospital beds, respirators, PPE in your state or community, you pretty quickly realize that we don’t have anywhere near the capacity for a full-blown COVID epidemic. Especially if healthcare workers are getting sick themselves.
Either act too early, or too late. Aggressive social distancing measures, even before there are confirmed cases, can slow the progression of the epidemic before it takes off. Americans are not particularly socialist by nature, but this is a case where individual sacrifices can collectively dampen the spike of an epidemic and save lives. Again, healthy people don’t need to seal themselves in their house. But be prepared for the cancelation of large events — concerts, sports events, political rallies, etc. I’ve been so impressed by the social consciousness of friends and family and the willingness to alter behavior, cancel plans, and think of the less fortunate. When local leaders and businesses start making very difficult decisions to cancel events, think about the 52 million Americans over age 65 and 133 million Americans with a chronic condition, and maybe resist the temptation to criticize. By the end of this, most of us will know someone who died of COVID, and in retrospect the sacrifices will seem small.
Week 10 (March 2-8)
It’s been a week since my post about COVID-19. Here’s the latest.
If you’re in a risk group (e.g., elderly*, underlying conditions), the time to think about social distancing has come. The virus is now transmitting in US communities. It may not be in your community yet. But we don’t know. You don’t have to seal yourself in your home, but you may want to avoid large gatherings. Try to be reasonable. Book club: probably okay. Going to a conference with 10,000 people and shaking everyone’s hand: probably less okay.
𝑵𝒐𝒏-𝒓𝒊𝒔𝒌 𝒈𝒓𝒐𝒖𝒑𝒔, 𝒘𝒊𝒕𝒉 𝒓𝒊𝒔𝒌 𝒈𝒓𝒐𝒖𝒑 𝒄𝒐𝒏𝒕𝒂𝒄𝒕
If you’re not in a risk group, you have less risk of severe disease. But if you get infected and have mild or no illness, you could still transmit the virus to someone in a risk group. So if you have high contact with people in a risk group, you may want to consider a degree of social distancing yourself. Again, being reasonable. Taking the dog to the park: okay. Taking a cruise: less okay.
I wish I could provide an app where you put in your age/health history and you could submit various activities (grocery shopping, Caps game, flight to Florida, attend granddaughter’s nursery school class) and the app would tell you the level of risk. Honestly, the data is just not there yet. We still don’t know, for example, how important children are in community transmission. You just have to try to use common sense and protect the vulnerable.
If the United States was China, I’d be confident that we could avert a major epidemic. China has effectively beaten back the virus without any vaccine or any special treatments. If you put society on lockdown, and practice extreme social distancing, you can break transmission and cases will drop, saving thousands, potentially millions, of lives. Italians have learned this lesson the hard way and have now initiated extreme lockdown of 16 million people. You know Italy is taking a virus seriously when they cancel the football games.
But we are not the Chinese. Or the Italians. We are the land of Don’t Tread on Me bumper stickers. And we are in an election year where politics come into play. Brace for a new meaning for March Madness.
*I intentionally use a vague term like ‘elderly’ because a fit 70-year old may be less risk than a frail 60-year old.
Week 9 (Feb 24 – Mar 1)
I’ve been fielding a lot of questions about COVID-19 lately. Here’s a summary from your friendly neighborhood epidemiologist:
1. 𝐘𝐞𝐬, 𝐭𝐡𝐞 𝐜𝐨𝐫𝐨𝐧𝐚𝐯𝐢𝐫𝐮𝐬 𝐢𝐬 𝐩𝐫𝐨𝐛𝐚𝐛𝐥𝐲 𝐜𝐨𝐦𝐢𝐧𝐠 𝐭𝐨 𝐚 𝐭𝐡𝐞𝐚𝐭𝐞𝐫 𝐧𝐞𝐚𝐫 𝐲𝐨𝐮. The testing criteria has been so restricted in the US, we’ve likely missed dozens of mild cases that were imported weeks ago. A vaccine will not be available for at least a year. Exactly when the virus will hit your community depends on a lot of factors, but it could be sooner than you think, so good to be prepared and informed.
2. 𝐒𝐡𝐨𝐮𝐥𝐝 𝐈 𝐛𝐞 𝐟𝐫𝐞𝐚𝐤𝐢𝐧𝐠 𝐨𝐮𝐭? At this precise point in time, an American is more likely to die of seasonal influenza than COVID. But that could change dramatically if COVID starts transmitting through the US population. COVID is far more deadly than seasonal flu, even accounting for uncertainty in the fatality rate.
The risk for severe disease follows a 𝒔𝒕𝒓𝒐𝒏𝒈 𝒂𝒈𝒆 𝒈𝒓𝒂𝒅𝒊𝒆𝒏𝒕, with most deaths in those over 70. That said, substantial mortality has also been observed in people in their 50s and 60s. And the millions of younger adults with chronic conditions (e.g., COPD, diabetes, hypertension) are also at risk. Testing has so far been so limited to severe cases so it’s hard to know what the denominator of mild cases is. But even a 1-2% fatality rate is extremely high [as context, Spanish influenza killed 20-50 million globally and had ~2% fatality rate in 1918}.
But the best news so far is that young children seem to be getting spared.
3. 𝐈𝐭’𝐬 𝐧𝐨𝐭 𝐭𝐨𝐨 𝐞𝐚𝐫𝐥𝐲 𝐭𝐨 𝐚𝐬𝐤 𝐲𝐨𝐮𝐫𝐬𝐞𝐥𝐟: 𝐝𝐨 𝐈 𝐡𝐚𝐯𝐞 𝐭𝐡𝐞 𝐬𝐮𝐩𝐩𝐥𝐢𝐞𝐬 𝐭𝐨 𝐬𝐡𝐞𝐥𝐭𝐞𝐫 𝐢𝐧 𝐩𝐥𝐚𝐜𝐞 𝐟𝐨𝐫 𝐰𝐞𝐞𝐤𝐬 𝐨𝐫 𝐦𝐨𝐫𝐞, 𝐢𝐟 𝐧𝐞𝐞𝐝𝐞𝐝. If you get infected and don’t require hospitalization, you may need to be self-quarantined in your own home for several weeks. Self-quarantine may also be an option for those at high risk when the epidemic is peaking in your community. Especially for retirees, teleworkers with existing health problems, you should think what degree of social distancing you can reasonably achieve. Between now and then, it would be good to think about stocking up on vital medications and essential supplies so you can minimize time in the community. It’s hard to know exactly how long a virus will be widespread in a given area. It’s a lot of complicated math that takes into account the characteristics of how the virus transmits and the demography and movement patterns of the community. It could be weeks, it could be months.
4. 𝐖𝐢𝐥𝐥 𝐬𝐜𝐡𝐨𝐨𝐥𝐬 𝐜𝐥𝐨𝐬𝐞? Japan’s recent decision to close schools is not because kids are at risk for severe disease, but more because the country is under enormous pressure from the 2020 Olympics and it’s not clear if kids with mild infections are important in community transmission. It doesn’t look like children are driving community transmission, but government officials at all levels will be under extreme pressure to show they’re doing something, and without a vaccine or therapeutics, school closings may be all they have.
5. Q&A section:
– 𝐂𝐚𝐧 𝐈 𝐞𝐚𝐭 𝐚𝐭 𝐂𝐡𝐢𝐧𝐞𝐬𝐞 𝐫𝐞𝐬𝐭𝐚𝐮𝐫𝐚𝐧𝐭𝐬?
– 𝐒𝐡𝐨𝐮𝐥𝐝 𝐈 𝐛𝐮𝐲 𝐚 𝐦𝐚𝐬𝐤?
Most masks only protect against large respiratory droplets, not the fine aerosols that transmit viruses. Masks tend to be most useful when worn by someone who is already infected to prevent infection to others.
– 𝐖𝐨𝐧’𝐭 𝐭𝐡𝐢𝐬 𝐚𝐥𝐥 𝐝𝐢𝐞 𝐨𝐮𝐭 𝐢𝐧 𝐀𝐩𝐫𝐢𝐥 𝐰𝐡𝐞𝐧 𝐭𝐡𝐞 𝐜𝐨𝐥𝐝 𝐬𝐞𝐚𝐬𝐨𝐧 𝐢𝐬 𝐨𝐯𝐞𝐫? Pandemics don’t follow typical seasonality. Recall that the 2009 ‘swine flu’ pandemic started in April and the first wave went through June. Even if coronaviruses are typically winter pathogens, when there are so many susceptible people in a community with no immunity to a novel pathogen, it can transmit fine outside their regular season.
– 𝐖𝐡𝐚𝐭 𝐚𝐫𝐞 𝐭𝐡𝐞 𝐭𝐡𝐢𝐧𝐠𝐬 𝐈’𝐦 𝐩𝐞𝐫𝐬𝐨𝐧𝐚𝐥𝐥𝐲 𝐦𝐨𝐬𝐭 𝐜𝐨𝐧𝐜𝐞𝐫𝐧𝐞𝐝 𝐚𝐛𝐨𝐮𝐭?
* The low availability of tests in the US.
* Health systems that lack the protective equipment, beds, tests, etc. needed to protect their workers on the front lines and serve their community during the peak of the epidemic.
* Politicization of the outbreak. The 1918 Spanish flu was one of the worst disease events in history, killing 20-50 million people, more than all world wars combined, and it was so bad because during the war politicians didn’t want to hurt morale and hid the details, exposing millions of people. They actually held huge war parades in cities in the middle of the epidemic. The best way to fuel an epidemic is to put politics ahead of transparency and information.