Surfing the COVID Third Wave: Where Do We Go From Here?
The experts told us it was coming—and now it is here, the fall surge in COVID-19 we have been warned of for months (https://www.cnn.com/2020/10/16/health/us-coronavirus-friday/index.html).
Our national response to the COVID-19 pandemic has consistently been far more reactive than proactive, so another failure of preparedness is really not surprising. Leadership in addressing the pandemic has been fragmented at best—and the tendency of our elected officials to use the pandemic as a tool for political gain has repeatedly undermined the very best efforts of our scientists. President Trump, in particular, has been a source of COVID-19 disinformation, consistently choosing to follow his own personal agenda over the advice of his healthcare advisors. State governments, largely left to chart their own courses, have been hit-or-miss in their responses. The result? The COVID-19 pandemic represents the single largest public health failure in our nation’s history.
So here we stand, the world’s richest nation, with the most COVID-19 cases and deaths on the planet—and now, the long-feared “third wave” is upon us at last (https://www.nytimes.com/interactive/2020/us/coronavirus-us-cases.html ).
The United States currently has recorded 8.1 million known cases of COVID -19 and 220,000 deaths. That’s about 20% of the world’s total for each of these categories, which is astonishing for a nation which comprises only ~ 4% of the world’s population. Contrary to some of the politically-motivated internet memes that are circulating out there, the COVID-19 numbers are not overblown nor fabricated. If anything, they are likely an underestimation of the true impact of the COVID-19 virus on our nation’s health care system. Moreover, any comparison to the flu (another popular bit of disinformation circulated in social media) is grossly inaccurate. Influenza A in the U.S. causes an average of between 12,000 and 61,000 deaths each year. COVID-19 will likely result in decade’s worth of influenza deaths solely during the year 2020 alone.
Since about 80% of all COVID-19 cases have either no symptoms or very mild symptoms, it has been estimated that the actual number of COVID-infected persons in the U.S. may be up to ten times higher than the number of known cases. In addition, recently published data looking at excess all-cause mortality capture the full impact of the pandemic on the health of our nation. Simply put, when a region’s health care system is overwhelmed, people with other health issues may not get adequate care—and some of them will die. A recent study published in the Journal of the American Medical Association looked at U.S. excess deaths (deaths which occurred during a specific time frame relative to similar historical time periods) and found that during the interval between March 1, 2020 through August 1, 2020 there were 1,336,561 total deaths in the United States. This was a 20% increase over similar historical periods, representing 225,530 excess deaths over the usual baseline. About 67% of this total was directly attributable to COVID-19. The remainder may be epiphenomena of the pandemic’s effect on U.S. healthcare (https://jamanetwork.com/journals/jama/fullarticle/2771841?utm_source=silverchair&utm_campaign=jama_network&utm_content=covid_weekly_highlights&utm_medium=email ). This study is demonstrable evidence of the indirect impact the pandemic has had on U.S. health care—for as health care facilities get overwhelmed, the folks who come in with strokes, heart attacks or gastrointestinal bleeding may not get optimal treatment. Others, concerned about possibly being exposed to the virus, may stay home and become more severely ill. Some of those individuals may die at home or might arrive at a health care facility when it is too late to save them. Additional indirect effects of the pandemic have included illnesses due to excessive ethanol intake (alcohol sales are up 23% nationwide), rising numbers of deaths due to drug overdoses and increases in suicides due to social isolation.
Incredibly, these figures are likely a further underestimation, of the impact of the COVID-19 pandemic. The impact of losing many of our usual preventative health care measures (colon and breast cancer screenings, blood pressure and diabetic control, etc.) may not be felt for many months or even years from now. This has been directly seen in Savannah, where the Savannah Morning News recently reported that screening mammography declined ~40% at both Memorial and at St. Joseph’s-Candler during the spring.
The United States is currently averaging more than 55,000 new COVID-19 cases per day. This is an increase of more than 60% since a mid-September dip in case volume. The Johns Hopkins COVID-19 database shows that 16 states or U.S. territories recently set records for new cases in a week. Many of these states were in the Midwest. Alaska, Colorado, Idaho, Illinois, Indiana, Minnesota, Missouri, Nebraska, New Mexico, North Dakota, Ohio, South Dakota, Utah, West Virginia, Wisconsin, Wisconsin and Guam all had their peak COVID-19 case levels last week. Cases are rising in many other states, as well; in fact, 29 states recorded a 10% or more rise in COVID cases over the previous week. Last week, the U.S. recorded the highest numbers of hospitalized patients with COVID since the end of August (https://www.washingtonpost.com/health/2020/10/15/coronavirus-cases-surging/ ).
Why this is happening is likely multi-factorial.
Cooler weather causes people to move their activities indoors. This increases the transmission of all respiratory viruses. In addition, COVID-19 viral particles are more stable in cooler, less humid environments. Temperatures have begun their usual seasonal drop in the upper Midwest, which has been a hotspot for COVID-19 recently. In addition, the Midwest was less severely impacted than the Northeast and the South earlier during the pandemic, resulting in a more vulnerable population in that region. The reopening of schools in many areas this fall has also contributed to the spread of the virus. Finally, there’s an element of COVID-associated “pandemic fatigue” at work currently, with many people gathering together for events such as weddings, parties, etc. after enduring months of social restrictions (https://www.nytimes.com/2020/10/17/us/coronavirus-pandemic-fatigue.html?referringSource=articleShare). All of this has resulted in a spike in cases—and this may only be the beginning (https://www.wsj.com/articles/why-covid-19-is-spreading-again-fatigue-colder-weather-eased-restrictions-11602759601).
What to Expect
With the advent of cooler weather, other respiratory viruses—including influenza—are bound to become more common. Combined with a surge in COVID-19 cases, this could lead to dangerously high hospitalization rates and ICU occupancy, which in turn could impact the ability of the health care system to perform at an optimal level. This is already being seen in Wisconsin, where a 500-bed field hospital was opened last week on the state fairgrounds outside of Milwaukee.
The Institute for Health Metrics and Economics at the University of Washington currently projects that COVID-19 will directly cause the deaths of ~390,000 Americans by February 1, 2021, with daily death totals nationwide peaking at ~2400 per day by the end of January. Universal mask-wearing could decrease this aggregate mortality figure by ~75,000 persons (https://covid19.healthdata.org/united-states-of-america?view=daily-deaths&tab=trend).
As cited previously, the indirect impacts of hospital and ICU overpopulation cannot be underestimated. Health care workers who have been dealing with the effects of the pandemic for over seven months now are mentally and physically fatigued. Many are burned out. Thousands have been made ill by COVID-19, and it has been estimated that over 1700 U.S. health care workers have died from the virus (https://www.fiercehealthcare.com/practices/report-how-many-u-s-healthcare-workers-have-died-from-covid-19-contracted-job). This is a dangerous combination of circumstances heading into what is certain to be a long, difficult winter. It is therefore incumbent upon all of us to do whatever we can to blunt the effects of COVID-19 transmission in our respective communities.
How Do We Fix This?
First of all, the whole idea of the population acquiring “herd immunity” through community transmission, as espoused by some, is simply not realistic. Herd immunity typically requires that the population have an infection exposure rate of ~70%. With a U.S. population of 330 million, this would mean allowing that 230 million Americans would need to get COVID-19. Based on what we know about the infection mortality rate (the percentage of COVID-infected patients who die of the disease or its complications), which has been estimated at ~0.5%, this non-strategy would result in the deaths of approximately a million Americans. That’s an unacceptably high price to pay for herd immunity
Secondly, while a number of vaccines are currently in development, it is unlikely that the clinical trials required to evaluate vaccine safety and efficacy for any vaccine will be completed before the end of November (https://www.usatoday.com/story/news/2020/10/16/pfizer-ceo-letter-makes-thanksgiving-earliest-date-covid-19-vaccine/3685200001/ ). Health care workers and at-risk persons would be vaccinated first, possibly by the end of 2020 (https://www.who.int/publications/m/item/draft-landscape-of-covid-19-candidate-vaccines). Widespread public vaccine availability therefore won’t be likely to happen until spring 2021—and that’s if everyone is willing to take a vaccine. A recent Wall Street Journal poll showed that half of all Americans were reluctant to take a COVID-19 vaccine—and 27% said they wouldn’t want to be vaccinated at all (https://www.wsj.com/articles/ahead-of-covid-19-vaccine-half-of-americans-indicate-reluctance-wsj-nbc-poll-finds-11602734460).
So what can I do now?
It’s going to seem repetitious, but there are three basic things we can all do to limit viral spread. We’ve heard them over and over again, but they are so critical that they cannot be emphasized enough:
· Good handwashing. It’s a simple fact: washing one’s hands, either (ideally) with soap and water or with a 70% alcohol solution, breaks down the outer envelope protein of SARS CoV-2 and kills the virus. Frequent hand-washing can be very effective in limiting viral spread. Avoiding physical contact with others, such as handshakes, and minimizing touching one’s face can decrease viral transmission, as well.
· Wear a mask. This has been endlessly debated in social media, but the objective data are clear: mask-wearing reduces both the risk of COVID-19 infection for the wearer and for those around him. A large meta-analysis by Chu et al published in the Lancet in June 2020 (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736) showed unequivocal benefits for mask-wearing as a limitation on the spread of respiratory viruses.
· Keep your distance. SARS COV-2 is a respiratory virus which requires relatively close proximity for the bulk of its transmission. As such, the whole idea of social distancing can be an effective weapon against viral spread. This means minimizing physical contact and keeping a distance of at least six feet (two meters) from most other people if at all possible. The efficacy of social distancing is enhanced by being outside and decreased by prolonged contact. As such, avoidance of enclosed spaces and prolonged contact (more than 15 minutes) with other individuals can improve the efficacy of this strategy. The Japanese government has emphasized avoiding the “Three C’s” to reduce the risk of infection: Closed spaces with poor ventilation, Crowded spaces and Close-contact settings in which people are talking face-to-face, singing or shouting.
Into the Breach
As we approach the holiday season, family gatherings may increase the risk of viral spread. The CDC has recommended that such gatherings be outside, if possible, of short duration and with small numbers of people—and that at-risk persons (the elderly, those with underlying health conditions, etc.) be excluded for their own protection. Persons who are at greater risk for transmitting COVID-19 also avoid such gatherings In addition, traveling for family events should be avoided to limit viral spread (https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/holidays.html). This all may seem like common sense, but common sense seems increasingly uncommon in today’s society.
It is unfortunate that the COVID-19 pandemic occurred during an election year. The winds of political change have altered our national and local responses to the pandemic to the point of abject confusion. I’m going to be very blunt here: This is going to be a hard winter. Many people will be sickened, and thousands will die. But there are things we can do to mitigate the effects of the pandemic, reduce our risk and limit the amount of stress on our health care system. For the sake of one another, we must do those things.
There is a glimmer of hope on the horizon. Treatments are improving, vaccines should be available within the next few months, and we will see the beginning of the end of this sooner rather than later. Until then, we have a responsibility to engage in a few simple measures which can insure our collective safety (https://ourworldindata.org/coronavirus). It’s past time we all took that responsibility seriously. Our lives—and the lives of many people we love—might be at stake. That fundamental concern, and not party politics, should be guiding our actions as we negotiate the dangerous shoals of the pandemic’s third wave.