ANN ARBOR – As I write this (March 11), 1269 cases and 37 deaths have occurred due to COVID-19 in the US. It may seem to the uninitiated that we are over-reacting to the threat. We are not.
I managed the development of the first test for HIV, the development and manufacture of six vaccines and managed Tamiflu during the H5N1 epidemic in Europe. From my experience, the US will be surprised at how much the country and our lives will be impacted through the epidemic’s projected peak in May. Successful interventions will not be a quick break and back to normal; they will be a long, inconvenient, circuitous path back to normalcy. Here is why
COVID-19’s potential to cause a pandemic is the result of three factors
- Transmission –This factor measures the ability of the virus to infect people. COVID-19’s rate of 2.2 additional people infected by each person infected is above the average viral rate of transmission. The big issue is that this is a new virus, so we have no natural immunity to it and will have no vaccines for at least one year. This increases transmission. Once it enters the body, COVID-19 takes up to 14 days for symptoms to appear which is much longer than average. This causes more transmission because the virus is transmissible but invisible to the sick and those around them for 2 weeks not just a few days. COVID-19 also is more transmissible because it remains viable and contagious longer than most viruses. Most viruses are not viable for more than three hours without their hosts. COVID-19 remains active for up to 3 days, so un-sanitized surfaces, hands and face remain contaminated for a longer time than for most viruses and bacteria. Finally, COVID-19 patients remain contagious after the disease peaks unlike most viruses that are not contagious after the disease is remitting.
- Virulence – This factor measures how severely the virus impacts its host once transmitted. COVID-19 mortality rate is 2.3%. This is an above average level of virulence (e.g., typically seasonal flu has a 0.1% mortality rate). The big issue is that the mortality increases linearly with age and exponential over 80 years of age. Unlike most viruses that kill the very young and the very old, COVID-19 has a 0.2% mortality rate for those under 18 but at 20%+mortality rate for patients over 80 years old with other complications and over 30% mortality rates if complicated by diabetes, heart disease, lung disease or hypertension. Infected, largely asymptomatic youth infecting the elderly is likely. The elderly immune system can over-respond to the virus, causing severe lung damage and leaving them susceptible to deadly subsequent bacterial infection as well. The inflammation and post-infections kill patients. Eighty percent of infections will be mild or asymptomatic.
- Mutation – This factor measures how stable the virus remains over time. The biggest risk we face is if COVID-19 mutates and becomes more transmissible and virulent. Deadly mutation of the Spanish flu caused mortality rates in 1918 to rise to 10 – 20% and killed 5% of the world’s population in 25 weeks. This is why early diagnosis and tracking of the disease is so critical. If a deadly strain emerges and is transmitted at COVID-19’s above average rate to the young, then death rates could spiral.
Right now we are dealing with an above average difficulty but medium-term manageable virus. In my experience, the next 2 -3 months will be very disruptive, around August things should be getting back to normal. In 18 months COVID – 19 likely will become a seasonal disease with a vaccine (separate from the flu vaccine).
Public Health Response
The US health system is more fragmented than in EU, Korea and China, where all citizens are insured and health policy is centralized. 27.9M Americans are uninsured and 39% of Americans under 65 years of age have high deductible health plans that cause them to forego testing and treatment that incurs out of pocket costs, especially early in the year. Additionally, 27.1 M people are part-time and 56.7% of the entire U.S. workforce is hourly. These people have no sick leave coverage and will likely continue to come to work even if they are sick. This is not the case in Europe or China. These factors will cause the US outbreak to be longer and more diffused than in China and Europe.
To reduce the length and severity of COVID-19 outbreak in the US, we must (in order of priority today)
- Establish Rapid Drive-through Testing Centers – To date less than 5000 people have been tested. Increasing testing levels by 100x COVID-19 rates are low and 5000x where it is high is required immediately. Testing allows us to track the disease. Testing must be free and without prior authorization requirements
- Expand Telehealth Service – Patients and healthcare workers must interact more on the phone to diagnose and monitor COVID-19 in real time. A 3x increase in these services are required. Cancel all healthcare professional vacations for the next three months. Expand the number of healthcare workers trained in treating COVID-19 (e.g. bringing physicians out of retirement) and then increase their access to telehealth infrastructures. This must occur now. Reimbursement for these services must be guaranteed with no patient co-pays. Expect 70% of healthcare workers to become sick with the virus.
- Manage Containment Zones. Establish clear measures for defining and enforcing containment zones. Expect 35% of our citizens will become infected generally and up to 80% in populated outbreak areas. Minimizing geographic hotspots and reservoirs will be critical to reducing mortality. Cancelling/rescheduling public gathering events where maintaining a 1 meter exclusion zone between attendees must be done now. Note that it is the concentration of people, not the absolute number of people (generally) that is critical to control the virus.
- Expand First Responder Staffing. Train National Guardsmen to provide first responder services now. Emergency services will be overwhelmed in pockets in the US. Supplementation plans for first responder services with nearby and National Guard support in highly impacted areas must be readied. Expect 80% of first responders to become sick with the virus.
- Make ICU Beds and Ventilators available. Hospitals in outbreak areas will be overwhelmed (ED and ICU especially). For example, up to 1M ventilators may be required to treat anticipated peak levels of the COVID-19 outbreak, but we only have 72000 full ventilator units across the US. Collectively hospitals are 100,000 ICU beds short of projected likely peak demand. Postpone all elective surgeries and convert standard beds to ICU capable units. Prepare for projected oxygen shortages and procure/store more oxygen and ventilation equipment now.
- Stock Protective Gear – The US hospitals currently have a one-day supply of masks and goggles on-hand to treat an outbreak. Hospitals in outbreak areas must grow this to a 7 day supply and nursing homes, dialysis centers, homeless shelters and prisons should make protective clothing (e.g., N95 masks) standard garb on-site (and limit visitors).
- Establish Mandatory Sick Day Leave for all workers – Congress must pass the pending bills now. If people “walk wounded” and continue to work in public areas while infected, the disease will be spread to others and progress in the individual. 78% of US workers work “paycheck to paycheck” and cannot afford to stop working due to illness. Working while sick will result in increased hospitalizations and higher infection rates and mortality rates.
- Fund Disaster Preparation Now. Anticipatd emergency infusions of cash to vulnerable smaller companies (e.g., travel companies, cruise lines or manufacturing plant-level “bailouts”) may be required. More critically, supporting welfare programs to vulnerable families will reduce the anticipated COVID-19 death rate. Anyone quarantined should be immediately eligible for unemployment insurance and those ill for Medicaid. Temporarily fund waiving work requirements for benefit programs. Fund temporary mortgage or rent relief for families struggling to provide or pay for care. This should look like the TARP funding during the 2008 financial crisis – focused and sufficient.
- Provide internet access and low-cost remote work capabilities. For students and workers with internet access and mobile phone or computer access, remote work options for everyone able to add value remotely should be provided the opportunity to work from home without prejudice through August. For those without internet access, hotspot access and laptops should be provided free of charge through August.
- Expanded Associated Healthcare Coverage. Reducing the overall mortality rate during this period will require treating diseases resulting from a COVID-19 infection like associated pneumonias and flu. Expanding free health privileges to patients with COVID-19 associated diseases will prevent progression keep them out of overwhelmed hospitals.
Personal Health Response
Do not be stupid! Be cautious. Over one-third of us are likely to contract this virus in the next 3 months and in some communities and professions infection rates will exceed 80%. COVID-19 is spread through respiratory droplets from infected people. The best way to prevent COVID-19 is to avoid exposure and use healthy habits. COVID-19 is agnostic to your politics, religion or nationality.
- Listen to Experts. Medical professionals, the CDC https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html, WHO and FDA experts only – not politicians, newscasters, advertisers or social media. Rumor will spread faster than truth – check sources before you act.
- Hand hygiene – Washing hands is best – wipe, soap and scrub under warm water for 20 seconds is best. The type of soap and heat of the water does not matter. If you cannot wash your hands with soap and water then sanitizing is your next best alternative. Stop touching your face. Wash or sanitize before touching your face and eyes or preparing food and after making direct contact with a person or public surface. Sanitize yourself and surfaces with sanitizers that are EPA certified to kill corona viruses. (e.g., Oxyvir wipes and spray was just approved for this). Bleach and highly concentrated (must be 70%+) alcohol-based hand sanitizers will also be effective. Do not DYI sanitizers. Wipe your hands to remove viral droplets, then sanitize and let it dry. After using the sanitizer, then wash your hands with soap and water.
- Work From Home. Get internet access/hot spot, buy a computer and work from home whenever possible and order purchased good online with home delivery.
- Keep Your Immune System Strong – Get sleep (7+ hours) . Get daily supply of vitamins (e.g., zinc, vitamin D3, Beta Glucan , minerals and nutrients. Drink six to eight 8 once glasses of water per day. Exercise 30 minutes per day alone. Humidfy and HEPA filter your air. Eat regular nutritious meals, including greens and fruits.
- Sanitize Non-Porous Surfaces Prior to Use. TV remotes, mobile phones, touch screens, door knobs, handles, light switches, steering wheels/shifters, purses/briefcases, airline seats/seatbelts/tray-tables, purchased items… should be wiped down with sanitizer wipes or sprays before use. Sprays are preferred (leave on for 3 minutes prior to wiping). Counter tops and public exposed surfaces should be cleaned at least daily. Use disposable wipes or wash your rags regularly. After being out, leave possibly contaminated clothes and items at the door, wear protection and sanitize them before bringing them into the home.
- Take Sick Leave if You are Sick. Know the symptoms of COVID-19 (I.E., fever, cough and shortness of breath) and be aware if you have come into contact with someone with these symptoms or are feeling them yourself. If you came into contact with a sick person, are positive for the virus or are sick, then stay home. Try to avoid consuming hospital services unnecessarily as a “worried well” patient. If you are sick, then wear a mask, keep your distance and self-quarantine yourself until you are completely well. Sanitize all items you breathed on or touched while ill and recovering.
- Cancel and do not take non–essential travel and visits. This is especially true for over 60 with chronic diseases. Do not take public transport or taxi/uber transport. Avoid jet travel.
- Isolate Yourself if you are over 60. If you are over 60 avoid all non-essential direct contact with people, especially friends and family who are young, have young children or are likely to be exposed to the virus – e.g., those traveling on planes, out and about, attending events, etc. If you are elderly and have diabetes, heart disease, lung disease, hypertension or kidney disease, you double your risk of dying of a COVID-19 infection. Stay home!
- Stock up now. Avoid having to make trips to the store and pharmacy for essential items. For example, get your medications filled for 3 months now. Plan to get sick for 5 days and buy food and water accordingly now. Have things delivered to your home – avoid going out. When items arrive, spray and wipe them down with a sanitizing agent.
- Wear Protective Gear as a Care Giver or as a Resident in Nursing Homes and Hospitals. If you are in a nursing home, restrict visitors, sanitize often and wear protective gear (e.g., professionally fit-tested N95 respirators)
- Get Flu and Pneumonia Vaccinations. You do not want to get the flu, pneumonia and COVID-19 all at once.
Fred Brown is President and Chief Operating Officer of Fred Brown Management Consulting LLC. His company provides C-suite strategy and operations consulting to healthcare providers, insurers and suppliers. You can find out more about Fred at https://www.linkedin.com/in/frederickwkbrown/