The Patchwork Pandemic: How hotspots ignite, and how we can avoid becoming one
Updated: Jun 2, 2020
The drumbeat of data goes on, every day: Over 6 million cases worldwide, 1.8 million in the U.S. A global death toll of over 370,000, with over 106,000 of those in the United States. We’ve heard about the disasters in Wuhan Province, Northern Italy, and Albany, Georgia, places where the ICUs were overwhelmed and thousands died.
And yet here in Chatham County, we’ve been far more fortunate: A mere 501 confirmed cases and 24 deaths since all of this began in a county with a population of nearly 300,000. Chatham County’s per capita case and mortality rates are among the lowest in the state—and the surrounding counties of the Coastal Health District are even better, with Effingham, Glynn, Tattnall, Liberty, Long, Emanuel, Wayne, Bulloch, Camden and McIntosh counties all with rock-bottom per capita COVID 19 infection and death rates, and Bryan County at a level only slightly above Chatham’s (https://www.nytimes.com/interactive/2020/us/georgia-coronavirus-cases.html). Far from being overwhelmed, our local hospitals have been able to resume performance of elective cases. Restaurants and businesses have re-opened. With the advent of springtime, things almost feel normal.
But things aren’t normal, not by a long shot.
I heard a quote by an epidemiologist this past week concerning the SARS CoV-2 virus, the virus that causes COVID 19: “If it’s anywhere, it’s everywhere.” Her point was that this virus is so insidious that it can jump through any crack in our public health defenses, snatching defeat from the jaws of victory. To quote the late Yogi Berra, “It ain’t over till it’s over.” And the COVID 19 pandemic is most decidedly not over—not by a long shot.
The key thing we are discovering about this pandemic is that although COVID 19 is a global phenomenon, the effects are local. The COVID 19 virus is highly contagious and causes little or no symptomatology in the majority of infected individuals. In fact, a recent study showed that 44% of secondarily infected patients were given the disease by patients who were not coughing or sneezing (https://www.nature.com/articles/s41591-020-0869-5). As a result, COVID 19 can be readily and widely transmitted. That’s the very nature of the problem: The guy sitting next to you on the bus going to work could be infected and not even know it. And yet we know that a small but quite significant segment of the population will have a very different sort of outcome. As we’ve delineated in this blog previously, older persons, those with pre-existing medical conditions such as diabetes, heart disease and chronic lung disease and people of color are at substantially higher risk for a bad outome, with ICU hospitalization or death (https://www.economist.com/science-and-technology/2020/05/21/the-risk-of-severe-covid-19-is-not-uniform). The overall U.S. case fatality rate for symptomatic individuals has been estimated at 1.3% by a University of Washington study. That’s over 10 times higher than influenza A. And for U.S. individuals over the age of 80, COVID 19 is lethal a whopping 13.4% of the time.
So are the citizens of the Coastal Health District going to skate through the rest of the COVID 19 pandemic relatively unscathed? A lot of that ultimately depends upon us.
When one looks at the map of the pandemic’s impact thus far in the U.S., one thing stands out: Large urban centers, where social distancing can be difficult, have been the hardest hit. New York City, the most densely-populated metro area in the U.S., and its surrounding areas were by far the most heavily impacted region in our country. Boston, Detroit and New Orleans also were hit pretty hard. But we are now seeing “hotspots” of COVID 19 erupt in other areas, including many areas which are suburban or even rural. Albany, Georgia was one regional example of an early hotspot, where a single infected individual managed to spread the disease to a large number of people through a couple of funerals and church services, resulting in about 2000 cases and 145 deaths in a county with a population of about 90,000. Another such hotspot in Georgia was in the Gainesville area, in Hall County, where an outbreak felt to be related to the area’s chicken processing plants resulted in 2500 cases.
Hotspots usually originate with an outbreak source. Gatherings of large numbers of individuals in enclosed spaces, such as church services, weddings or dinners, have been implicated. Nursing homes, factories, prisons and meat processing plants have been major sources of outbreaks. The Washington Post recently cited a striking statistic: Among the 25 rural U.S. counties with the highest per capita rates, 20 have a meatpacking plant or a prison where the virus took hold and spread, then leaped into the community when the workers in those facilities took it home. The Post article also described how the virus erupted in a pork processing plant in the Oklahoma panhandle and in a pair of nursing homes in eastern Colorado, rural areas with few health care resources and large numbers of immigrant populations, many of whom have no health care benefits and live under crowded conditions. Dr. Tara Smith, an epidemiologist at Kent State University in Ohio, described the evolution of the pandemic across rural America as a “checkerboard,” with hot spots that come and go (https://www.washingtonpost.com/nation/2020/05/24/coronavirus-rural-america-outbreaks/?arc404=true). That seems to be the reality of COVID 19 going forward. Our goal locally, and the goal of every community, should be to avoid becoming a hot spot of viral activity.
Nursing homes are a major source of COVID 19 infection. The first large U.S. outbreak occurred with a King County, Washington nursing home as its epicenter. According the the Centers for Medicaid and Medicare Services (CMS), the federal agency which oversees nursing homes, over 60,000 U.S. nursing home residents have been infected with COVID 19 and 25,000 have died. In addition, 34,000 nursing home staff have become infected, with another 400 deaths in that population.
The Food and Environment Reporting Network has documented over 22,000 COVID 19 cases and 76 deaths at 245 meat-packing and food processing plants across the country (https://thefern.org/2020/04/mapping-covid-19-in-meat-and-food-processing-plants/0). An outbreak at a Tyson chicken plant in Iowa resulted in the infection of 730 employees, or 58% of its workforce (https://who13.com/news/covid-19-state-of-iowa-releases-new-details-on-workplace-outbreaks/).
A prison outbreak at the Marion Correctional Institute in Ohio infected 80% of the prison population and over 160 corrections officers and other staff. The Marshall Project, a state-by-state look at coronavirus in prisons, has documented nearly 35,000 COVID 19 infections among inmates, and 455 deaths. In Georgia, which had the first documented COVID 19 death among inmates in the entire country on March 26, there have been 430 COVID 19 cases among prisoners and 17 deaths (https://www.themarshallproject.org/2020/05/01/a-state-by-state-look-at-coronavirus-in-prisons).
Although the COVID 19 pandemic is global, its impact is invariably local. Savannah has been very fortunate thus far. In order for Savannah and the rest of coastal Georgia to continue to avoid the tragic potential consequences of the COVID 19 pandemic, we must not let our guard down as the economy reopens. We all need to pay attention to the little things that will limit disease spread. Continued social distancing, regular hand-washing, testing and isolation of infected individuals and, yes, mask-wearing in public places (especially indoors) are all things we can do to help curb the spread of the virus locally. One point to be clear about: There is no indication that SARS CoV-2 is going away any time soon. Hot weather isn’t going to dissipate it. We are simply going to have to live with this thing until a vaccine is available—and that may be up to a year away.
So how do we do this?
Social distancing was a term few had heard of prior to the current pandemic, but if you haven’t heard the term by now, you’ve been living under the proverbial socially-distant rock. It is unequivocal that the largest super-spreader events have occurred when large groups gather together, usually indoors. Anecdotal accounts have included events at a church and a business call center in South Korea (https://www.theatlantic.com/ideas/archive/2020/05/whats-south-koreas-secret/611215/), a choir practice near Seattle, and a packed prayer meeting in France. A Biogen corporate meeting in Boston during early March resulted in at least 100 cases of COVID 19. Indoor exposures provide a particular risk. A paper awaiting peer review which was written by researchers from Hong Kong found that of 7324 COVID-19 cases in China, only one small outbreak was linked to outdoor exposure (https://www.medrxiv.org/content/10.1101/2020.04.04.20053058v1.full.pdf). A Japanese study showed that the risk of a primary case of COVID 19 transmission in a closed (indoor) environment was nearly 19 times higher than the same risk in an outdoor environment (https://www.medrxiv.org/content/10.1101/2020.02.28.20029272v2.full.pdf).
What can we do going forward? For starters, until this is all over, we should likely avoid large gatherings—and if you do go to one, wear a mask. If you dine out, try to dine outside. Minimize face-to-face meetings at work—and wear a mask if you have them. Avoid crowded venues. Be extra careful about being involved in indoor activities that involve lots of singing (choir practice), talking (meetings), or heavy breathing (gyms), as these are more likely to result in aerosolization of particles which could then be transmitted. And you should be extra careful if you are working in a high-risk environment such as a meat-packing plant, medical facility, prison or nursing home.
About those masks
There are some people who have made anti-COVID measures into a political issue, stubbornly insisting that they won’t wear a mask because it is a “violation of their rights.”
To put it bluntly, those people are wrong.
The measures advocated to curb the spread of COVID 19 involve issues that potentially affect the health of the greater community—and individual “rights” cannot supersede the interests of public health. The reason “Typhoid Mary” Mallon was twice quarantined on North Brother Island in New York (the second time for the remainder of her life) was because she refused to stop serving people food even though she had been identified as a typhoid carrier. She was a public health hazard. And during the COVID-19 pandemic, anyone who refuses to wear a mask in public is a potential public health hazard, too.
There are pretty good scientific data behind this. Research has shown that even a cotton mask can reduce the number of virus particles emitted from our mouths—by as much as 99% (https://www.nejm.org/doi/full/10.1056/NEJMc2007800). And since a lot of infected persons are transmitting the virus when they are not symptomatic, universal mask-wearing can be very effective in reducing virus transmission. The mathematics of this are impressive. In epidemiology, every infectious disease has a transmission rate (R0). An infectious disease with an R0 of 1.0 means that every infected person, on average, infects one other person. The baseline R0 of SARS CoV-2 is at least 2.4 and may be higher. If the effective R0 for an infectious disease drops below 1, the disease will die out. Mathematical modelling suggests that if 80% of the people in a community wore a mask in public, the effective R0 for SARs CoV-2 would drop below 1 (https://www.fast.ai/2020/04/13/masks-summary/). In other words, the disease would not be able to transmit itself, and would die out. This conclusion has been backed up by field data. South Korea’s universal mask-wearing has been instrumental in curbing its pandemic. Hong Kong, with an almost 100% compliance rate for public mask-wearing, has shown similar results (https://www.sciencedirect.com/science/article/pii/S2468266720300906).
Remember, the main reason you’re wearing is mask is not for you. Instead, it’s for everyone else. Mask-wearing has nothing to do with the individual freedom of the mask-wearer. Instead, it’s about the right of every citizen to remain healthy and disease-free. When you wear a mask, it’s really an act of charity towards one’s fellow man—and that’s something we could all use a little more of these days.