Tuesday, March 24, 2020

Ask Science: Ending Social Distancing Now is a Deadly Idea

Below is an illuminating Twitter thread from yesterday that I copied and pasted here from Tom Inglesby, Director of the Center for Health Security at the Johns Hopkins Bloomberg School of Public Health. Dr. Inglesby has an MD from Columbia University and completed his internal medicine and infectious disease training at Johns Hopkins. He sees patients in a weekly infectious disease clinic. I’ve lightly edited this only for non-Twitter clarity.

In last 24 hours there've been prominent US voices calling for a stop to social distancing, citing rationale that they're worse than impact of COVID itself. It’s worth looking very closely at that claim, where we are in the US COVID epidemic, and what happens if we stop.

COVID has been spreading with exponential growth in the US for some time, and we're just beginning to get an understanding of how extensively. There are nearly 40,000 cases recognized in the US as of today, with about 100 deaths today. A few weeks ago, we had recognized 70 cases total.

Some hospitals have said publicly that within a week they will not have ventilators to treat everyone with COVID anymore.

There continue to be big diagnostic limitations.  Shortages in reagents, swabs. We don’t have rapid diagnostics in many hospitals yet, so it can be days before doctors and nurses can find out if a patient in front of them has COVID.

We don’t have capacity to diagnose many of the COVID cases that are not sick enough to be in the hospital, so those numbers aren’t counted in our national totals.

There continue to be terrible shortages in the masks that health care workers need to keep from getting sick with this disease.

How do we gain time to let hospitals get more supplies and prepare for high number of patients? How do we lower the speed of spread of COVID in the US?  How do we lower the odds that ICUs will run out of ventilators and hospitals will run out of space?  

The answer for now is large scale social distancing.

In Asia, we've seen these interventions work to lower
the pace of the epidemic, lower numbers of critically ill, lower the number of people who get COVID. In
Asia where big social distancing measures have been in place for two months, they have had very strong impact. 

In Asia they've slowed the disease by slowing social interaction. Left to its own, this disease spreads from 1 person to about 2.5 people, and then they do the same, and so on. For this disease to stop, we need to make it so that the average person spreads it to <1 other person. 

These big social distancing measures take time to work. The impact of big interventions in Wuhan China took about three weeks to start to reverse things. And then everyday after the situation got better. In the US, we're about 7 to 10 days into this, depending on the state.

To drop all these measures now would be to accept that COVID patients will get sick in extraordinary numbers all over the country, far beyond what the US health care system could bear.  

Many models report that health care systems will be completely overwhelmed or collapse by the peak of cases if major social distancing is not put in place. 

If a health care system in a given community stops working, and can no longer provide care to the ill, the case fatality rate for COVID will be far higher than 1%. We would not be able to care for some or all of the expected 5% of recognized cases that get critically ill.

Beyond that, if hospitals were completely overwhelmed, they may struggle to provide even oxygen for some or many of the 15% of recognized cases expected to be “severely ill,” let alone provide care for other life-threatening conditions.

Anyone advising the end of social distancing now needs to fully understand what the country will look like if we do that. COVID would spread widely, rapidly, terribly, and could kill potentially millions in the year ahead with huge social and economic impact across the country.

Before considering big changes to social distancing measures now, we should as quickly as possible get to the strongest possible position for COVID response – we're nowhere near that now.  We'll need rapid diagnostics in place at almost every location where a patient can be seen for care.

We'll need extraordinary quantity, reserve, and production lines of masks and PPE so that shortages at hospital and clinical sites around the country
are no longer possible. We'll need to have more ventilators on the way. We'll need capacity to provide medical care to many more that we can now.

We'll need to reduce the number of cases to such a low level that we could again do contact tracing and isolation of cases around the country (as they can in many countries in Asia now).

We will need a system of screening at airports
so that no person comes into the country with the disease without being diagnosed and isolated.

We'll need a serology test that can be used to identify those that have been infected and recovered already, and to know how prevalent the disease is in the US.  We would hopefully have therapies developed and in a quantity that we can treat at least the sickest patients with COVID.

Once we have those things in place, it would be a far less risky time to take stock of social distancing measures in place and consider what might gradually be reduced with trial and error. We would have learned more about the experience in Asia as they try to do that.

For now we need to keep production running, doctors offices working, groceries, pharmacies, and banks open. It is ok to have science-informed dialogue about which businesses need to be closed versus what can stay open in some way if social distancing can be put in place in them.

But we need to press ahead for now with closed schools, mass telecommuting, no gatherings, strong advisory to stay home unless you need to go out – all are needed to slow this epidemic.

We also need to put every conceivable economic program in place to help those being hurt by these social distancing measures. And move ahead rapidly to get our country far better prepared to cope with COVID before people recommend we abandon our efforts to slow this virus.

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