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Crossroads: Where does the COVID-19 pandemic go from here?


I wrote my first entry in this blog almost exactly 8 months ago. It was the week my hometown of Savannah, Georgia recorded its first documented case of COVID-19, the infection which has subsequently defined the entire landscape of the year 2020.


Today, we find ourselves in a profoundly changed world.


Chatham County has documented over 10,500 cases of COVID-19. Over half of these cases were in people under 40. The largest affected group was among 20-29-year-olds, with over 2500 cases. As of November 27, a total of 200 Chatham County residents have died of COVID-19 or its complications. The majority of these local deaths (123, as of this writing) were in persons over the age of 70 (https://covid19.gachd.org/cumulative-cases-deaths-by-age/).


The state of Georgia has documented over 465,000 cases, with 35,000 hospitalizations, 6500 ICU stays and 8746 deaths as of November 27. Nationally, the official U.S. tallies are 13,500,000 cases and 271,000 deaths—by far the most in the world (https://www.worldometers.info/coronavirus/country/us/ ).


Unfortunately, that’s just the tip of the iceberg.


It has been estimated that 84% of Americans infected with COVID-19 are either asymptomatic (40%) or minimally symptomatic (44%). As such, a recent study in the medical journal Clinical Infectious Diseases suggested that only 1 out of every 7 cases of COVID in this country was detected (https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa1780/6000389 ). Extrapolating that figure to currently available national data, that would mean that between 90 and 100 million Americans may have actually already been exposed to COVID-19, or a little less than a third of the country.


The virus has been spreading almost unchecked in recent weeks. The U.S. has reported over 100,000 infections per day for 25 consecutive days (there were over 205,000 new cases reported nationally on the Friday after Thanksgiving), with over a million new cases of COVID-19 reported during the week before Thanksgiving. The number of people currently hospitalized with COVID-19 in the U.S. has hovered just below or right at 90,000 for the last week, which is a record. Deaths remain high, as well: Every day, we are currently seeing about 1500 Americans die from COVID-19.


Georgia is showing an uptick, as well: both the numbers of COVID-19 cases per 100,000 population and the numbers of hospitalized patients have increased over the past week. As of Friday, November 27, there were 1985 Georgians hospitalized with COVID-19.


The Thanksgiving holiday, with millions of people traveling to visit family nationwide, has health care officials concerned about a post-holiday spike in cases. Although the CDC recommended that people not travel for the holiday, that recommendation was not followed by many. Given that small gatherings of unmasked persons indoors are prototypical venues for viral spread, it is anticipated that the next few weeks will see a significant rise in both diagnosed and hospitalized COVID-19 patients. The IHME database at the University of Washington currently projects that 471,000 Americans will die as a result of COVID-19 by March 1, 2021 (https://covid19.healthdata.org/united-states-of-america?view=total-deaths&tab=trend). That would make COVID-19 the third-leading cause of death in the U.S. for the past year, right behind heart disease (655,000 deaths annually) and cancer (600,000 deaths annually) (https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm ). With these numbers, COVID-19 would be the second-leading infectious disease cause of death during any one year in U.S. history, after the infamously deadly 1918 H1N1 influenza pandemic, which caused an estimated 675,000 Americans to die over a two-year period during the pre-vaccination era (https://www.history.com/news/spanish-flu-second-wave-resurgence ).


The upcoming Christmas holidays will represent yet another challenge. Minimally symptomatic college students coming home for the holidays could transmit COVID-19 to their more-susceptible parents and grandparents, leading to a post-holiday surge in illness which could dwarf the prior spikes of the virus in spring and summer. Prior viral spikes have strained hospital systems in parts of New York, Texas, Louisiana, Arizona, Wisconsin and the Dakotas to the breaking point—and the virus’s increasing prevalence in rural areas threatens to do the same throughout smaller communities nationwide (https://www.nationalgeographic.com/science/2020/11/coronavirus-smoldered-in-rural-america-for-months-why-everyone-missed-it/ ). This sort of strain leads to increased deaths in other areas as patients with non-COVID problems receive less-than-optimal care due to the plethora of resources being diverted to the COVID population.


So far, nine states (New York, New Jersey, Massachusetts, Connecticut, Louisiana, Rhode Island, Mississippi, North Dakota and South Dakota) have hit a grim milestone: 1 out of every 1000 residents in these states have died of COVID-related illnesses (https://www.washingtonpost.com/nation/2020/11/27/covid-coronavirus-update-black-friday/ ). These figures do not take into account the excess deaths due to over-strained local health systems or due to people not seeking assistance for urgent issues due to concerns about contracting COVID-19. A recent study in the Morbidity and Mortality Weekly Report noted that from late January through October 3, 2020, the United States had 299,028 excess deaths relative to the average numbers from prior years. Of these, 198,081, or ~66%, were directly attributed to COVID-19 (https://www.cdc.gov/mmwr/volumes/69/wr/mm6942e2.htm ). The actual mortality cost for the pandemic is therefore even higher than the number of actual recorded deaths directly attributed to COVID. Moreover, the impact of people not undertaking standard routine preventative health care measures (hypertensive and diabetic control, routine screening colonoscopies, mammograms and PAP smears, for example) due to the pandemic may not be fully understood for years.


Despite these sobering statistics, there is hope on the horizon. The preliminary efficacy data on several COVID-19 vaccines, after less than a year’s development time, was nothing short of astonishing. Both the Moderna vaccine and the Pfizer vaccine showed efficacy rates of around 95% (https://www.cnn.com/2020/11/16/health/moderna-vaccine-results-coronavirus/index.html ) and the Oxford/Astra Zeneca vaccine showed about a 90% efficacy rate. How do these figures compare with other vaccines? Well, the gold standard is the measles vaccine, which is 97% protective after two doses, so the COVID-19 vaccine data compare favorably with that figure. By contrast, the 2019-2020 seasonal flu vaccine had an efficacy of only ~ 45% (https://www.cdc.gov/mmwr/volumes/69/wr/mm6907a1.htm).

The Moderna and Pfizer vaccines are now up for FDA approval, and at least 32 other vaccines are well into the pipeline, with Phase III clinical trials ongoing. Once approved, these vaccines can be distributed for use. Pfizer has already made plans to ship 20 million doses of its vaccine (enough for 10 million people) before the end of December 2020. Moderna has done the same, meaning that 20 million persons can likely be vaccinated by the new year.


It is anticipated that health care professionals and high-risk individuals (i.e. elderly nursing home residents) will receive the first doses of vaccine. The CDC estimates that there are 21 million health care personnel in the U.S., so they will likely be the first persons vaccinated. Another hundred million persons high high-risk health conditions; they will likely comprise the second group. The remainder of Americans should have access to a vaccine by spring of 2021 (https://www.nytimes.com/2020/11/17/health/coronavirus-vaccine-operation-warp-speed.html?referringSource=articleShare ).


COVID-19 vaccines can be distributed within 24 hours of authorization by the FDA. McKesson Corporation will be a centralized distributor of most of the COVID-19 vaccines with the exception of the Pfizer vaccine, which has its own distribution network. The vaccines will be distributed to pharmacies, hospitals, doctors’ offices and other health care facilities as soon as it is available. CVS and Walgreens will vaccinate residents and staff at long-term care facilities. It is anticipated that there will be enough vaccine manufactured to inoculate 25-30 million people a month starting in January (https://www.wsj.com/articles/the-covid-19-vaccine-when-will-it-be-available-for-you-11606339361 ). Widespread vaccination will hopefully be the final step towards achieving so-called “herd immunity,” typically reached when ~70% of a population has antibodies to the virus, either via exposure or vaccination. Of course, some of that is at least somewhat contingent upon public behavior; a recent Gallup poll suggested that only 58% of Americans are willing to take a first-generation COVID-19 vaccine when it becomes available (https://news.gallup.com/poll/325208/americans-willing-covid-vaccine.aspx ).


On the good news front, it looks as though COVID-19 immunity is durable, possibly lasting for years (https://www.nytimes.com/2020/11/17/health/coronavirus-immunity.html?referringSource=articleShare ). While reinfection can occur, it appears to be rare.


If a vaccine is not available for most Americans until spring, what can we do in the interim to limit our risk and the risk to our loved ones? As we have developed a better understanding of SARS CoV-2, the virus responsible for COVID-19, there are a few things which we can do to limit viral spread and get through the next few months until the vaccines become widely available.


· First of all, don’t spend lots of time indoors with other people. The odds of transmission of COVID-19 increase by 18.7 times in closed environments as opposed to open-air environments. Certain environments such as bars, indoor restaurants, gyms and church sanctuaries (where people are more likely to be talking, singing, breathing heavily or shouting) are higher-risk, and should be explicitly avoided if at all possible (https://www.medrxiv.org/content/10.1101/2020.02.28.20029272v2 ). Indoor restaurants have been specifically associated with virus transmission https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a5.htm ). However, even the exclusion of these higher-risk environments may not be enough. Transmission of COVID-19 among smaller gatherings has also been well-documented (https://www.washingtonpost.com/health/2020/11/12/covid-social-gatherings/ ). Limiting gatherings to less than 10 people, having a shorter duration of contact (15 minutes or less during a 24-hour period), the universal wearing of masks and pre-exposure testing can all limit one’s risk if one must be indoors (https://www.washingtonpost.com/health/2020/10/21/coronavirus-close-contact-cdc/ ). One writer likens the combined use of such measures to using layers of “Swiss cheese.” Each layer has a few holes in it, but used together, they can at least mitigate some degree of risk in environments where full measures are not possible.


· Second, wear the damn mask. It has been relatively conclusively proven that universal mask-wearing can retard the transmission of COVID-19. There’s really not much controversy about this in the medical community at this point, and any other points that are made to the contrary are predicated largely on political considerations, not science. The CDC website, now largely freed of the informational shackles which bound it during the run-up to the recent presidential campaign, illustrates the current recommendations here: https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/cloth-face-cover-guidance.html. Even Republican governors, faced with their states’ hospital systems potentially being overloaded with COVID-19 patients during the coming winter months, are on board with universal mask-wearing these days (https://www.nytimes.com/live/2020/11/17/world/covid-19-coronavirus?referringSource=articleShare#after-holding-out-republican-governors-reverse-course-and-issue-mask-mandates).


Universal mask-wearing protects everyone. Failure to utilize mask-wearing as a tool, given the preponderance of objective data supporting mask-wearing as a method of pandemic control, is not only rude, it’s public health malpractice.


What masks work? While standard surgical masks and N95 respirator masks are certainly effective, some have advocated limiting their use to health care professionals so as to conserve the supply of those items for medical use. Cloth masks are therefore recommended for general use. The most effective cloth masks are those with 2 or 3 layers, woven of cotton or cotton blends, which are breathable. The least effective cloth masks are loose knit fabrics or masks that are difficult to breathe through, like plastic or leather. Masks with exhalation ports also are not as effective at limiting virus transmission.


· Third, wash your hands. Using soap and water, or an alcohol-based sanitizer if soap and water are not available, is the most effective way to limit surface-related transmission. Also, avoiding close physical contact (handshakes, hugs, etc.) is strongly recommended.


· Don’t forget social distancing. Given that SARS CoV-2 I is primarily a respiratory virus, limiting one’s exposure by staying at least six feet from others if at all possible is recommended. This means avoiding large crowds—especially indoors. Note, also, that mask-wearing is NOT a substitute for social distancing. All of these measures should be taken in aggregate to minimize one’s risk.


Former CDC Director Thomas R. Frieden, writing in The Atlantic, recently said that “Every infection is a step in the wrong direction, and every infection prevented is a step toward health and economic recovery (https://www.theatlantic.com/ideas/archive/2020/11/covid-19-is-out-of-control-what-can-we-do/617097/ ).” We must keep this tenet in mind when addressing our community needs during the long and difficult winter ahead. It’s time we stopped using viral response public health techniques as political tools and instead started using science-based initiatives to help one another get through this.


We Americans are all in this together. It’s long overdue that we started acting like it.


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