By Dr. Maura McLaughlin
Editor’s Note: The Gazette asked Dr. Maura McLaughlin, a family medicine physician with an independent practice in Crozet, to help us understand where we stand now with COVID-19 and what we should do next. Without naming names, your editor certifies that the virus is bona fide here in Crozet. We give our sincere thanks to the health care professionals who confront it for us, and who seem to be winning. May angels defend them. As a scientist, Dr. McLaughlin naturally supports all her data and facts with sound sources. Her report below contains 32 citations that were omitted from the print edition for space, but links are included here. — MM
COVID-19: Where we are now
Please note that while this information is current as to my knowledge at the time of this writing, we are learning more every day about this virus, and recommendations may change moving forward.
I warn you that much of what I have to tell you is bad news. Naturally, I like to deliver good news to my patients. Sometimes, though, I must tell patients bad news that will profoundly alter their lives. It is necessary to convey the facts if we are to share any understanding of the reality we are facing.
First: some vocabulary so we are all on the same page. COVID-19 is the disease caused by the SARS-CoV-2 virus. The SARS-CoV-2 virus is a member of the coronavirus family of viruses, and the term “coronavirus” is frequently used to refer to both the SARS-CoV-2 virus and to the COVID-19 disease.
The first confirmed case of COVID-19 in Virginia was reported on March 7. We had 130 new COVID-19 cases on March 30, when Governor Northam signed the initial stay-at-home order for Virginians. On June 26, Virginia reported 624 new cases of COVID-19. At our peak in Virginia, we had just over 1,000 new cases daily. While new cases have trended down from that initial peak, the news is not all good. New daily cases have been fairly stable over the past two weeks, rather than declining further as we hoped to see.
The overall trending down of overall daily cases in Virginia is likely linked mainly to the decrease in daily cases in the hard-hit areas in Northern Virginia. While that area is doing better overall, daily case numbers are currently increasing in certain areas of Virginia, including Albemarle, Augusta, and Greene counties.
Albemarle county, to date, has had 374 identified cases, 27 hospitalized, and 8 deaths. Charlottesville, which is reported separately from Albemarle county, has had 196 reported cases, 17 hospitalized, and 3 deaths.
If you look at just a snapshot of how many new cases there are in any area, you might think to yourself, well, that is not so bad, that is just a tiny fraction of the people here. The important fact to keep in mind is that because this is a virus, it spreads, literally, virally. Scientists measure this spread by a num-ber called R0, or “R naught.”
In Virginia, the R0 for SARS-CoV-2 was measured at 2.2 before stay-at-home measures took effect. The R0 has been measured much higher in other parts of the world (5.7 in Wuhan), possibly due to differ-ences in population density. In comparison, influenza has an overall R0 of 1.3. Thus, influenza spreads among a population more slowly than this coronavirus.
What does this R0 of 2.2 mean for the spread of coronavirus in Virginia? Using an R0 of 2 for easy math (which will actually underestimate the speed of spread), let’s see how quickly this coronavirus in-fection could spread if no measures were in place to stop it. If one person in Crozet has this virus, and passes it to two others, and those two pass it to two others:
Within just 15 steps of transmission, the virus has gone from just one case to more than 16,000 people.
How fast will this happen? Most people develop symptoms of COVID-19 within 2-14 days of exposure, with most people developing symptoms around day 5. People appear to be most contagious just before developing symptoms and then in the early days of symptoms. So, we can estimate that if each person infects someone else around day 5 on average, within two and a half months, that one initial person will have started a viral chain reaction that will have infected more than the entire population of our small town. If we continue to let it spread un-checked, then we can estimate that within another 10 steps of transmission, which would take less than two more months, the virus will have spread to 16.8 million people, almost double the population of Virginia.
A typical virus spreading to this many people is not necessarily a huge problem. We see widespread transmission of many different common cold viruses every year. The problem is when a virus, like SARS-Cov2, makes people very sick and kills them. The death rate from infection is known as the infec-tion fatality rate (IFR). Scientists are working very hard to determine what this rate is for SARS-CoV-2, and current worldwide estimates suggest that it is somewhere between 0.5% and 1%.
The estimate of 0.5-1% fatality includes both people who have symptoms and those who have no symptoms from infection. The infection fatality rate-symptomatic (IFR-S) is a category that includes only symptomatic cases. The IFR-S for COVID-19 is currently thought to be 1.3%. As a comparison, the IFR-S of seasonal influenza is 0.1%.
So, there are two features of coronavirus that make it much more worrisome than the flu:
- Coronavirus spreads more quickly within a population—affecting more people in the same period of time
- If you develop symptoms from coronavirus, it is, on average, about 10 times more likely than the flu to kill you
Both of these factors add up to many, many more potential deaths from coronavirus than we have seen in recent years from seasonal influenza. CDC estimates somewhere between 24,000 and 62,000 U.S. deaths from seasonal influenza from October 2019 to April 2020, and reports 124,325 U.S. deaths from COVID-19 in 2020 as of the writing of this article. The number of U.S. deaths due to COVID-19 will undoubtedly have increased by the time this article is published.
These may just sound like numbers, until your loved one is the person in the hospital bed diagnosed with COVID-19, and the door to their room is closed, with you outside, unable to give them a hug or hold their hand.
Planning for the Future
According to the Center for Infectious Disease Research and Policy (CIDRAP), based on the past influenza pandemics, this COVID-19 pandemic may last a total for 18 to 24 months total. (See “COVID-19: The CIDRAP Viewpoint April 30th, 2020 Part 1: The Future of the COVID-19 Pandemic: Lessons Learned from Pandemic Influenza” for much more detail about what those months could look like.)
During this time, we all will need to continue to make informed decisions for ourselves and our fami-lies about how to engage in a world with coronavirus present.
When attempting to plan in the time of this pandemic, I think it’s helpful to remember the words at-tributed to Wayne Gretsky: “A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.”
Especially because this virus, in the absence of social distancing measures, spreads so quickly, it is im-portant to look to where we are headed. Even if the numbers in the moment look good, as we saw above, one case in an area can spread very quickly without measures to contain it.
Recognizing trends of increasing or decreasing cases allows us to understand is working and what is not. Paying attention to hospitalizations and deaths is helpful, too. It is important to note that an in-crease in cases often will not show up as an increase in hospitalizations for a week or so, as people who are hospitalized often have an infection that began a week or so before hospitalization. An increase in cases will often not show up as an increase in deaths for weeks, as once people are seriously ill, they may be hospitalized for weeks before either recovering or dying. It important to act early, as once the numbers get too high, it is much more difficult to get the spread under control.
Risk Factors for Serious Complications from COVID-19
Age has been widely recognized as a significant risk factor for COVID-19. The risk is much higher for older adults, but it is still present for all ages. I am in the age group 40-49 years, and a death rate of 0.4% means that overall, in my age group 1 out of 250 people who are diagnosed with COVID-19 will die from it. For younger adults, that risk is 0.2%, or 1 in 500.
Underlying health conditions have also been widely discussed as risk factors for serious illness.
The CDC recognizes the following conditions as placing people at increased risk: chronic kidney dis-ease, COPD (emphysema), immunocompromise from solid organ transplant, obesity (BMI 30 or high-er), serious heart conditions, sickle cell disease, and diabetes mellitus type 2.
Data in the US have shown that obesity is a major risk factor, and in fact, for people under 55 years, obesity is the number one risk factor for severe COVID-19. Data out of China showed that cardiovascular disease, diabetes, chronic lung disease, high blood pressure, and cancer were all major risk factors.
A recent report estimated that 4 in 10 adults in the US (37.6%) have a higher risk of developing serious illness if they become infected with coronavirus, due to their older age (65 years and older) or health condition.
The COVID-19 pandemic has highlighted racial disparities in health outcomes, with Black, Latino, and Native American populations at risk of disproportionately high rates of infection and severe illness.
You may feel, after reviewing this information, that your personal risk of becoming seriously ill or dying from the coronavirus is low, and you may be right.
However, we each must also consider the effect that our actions have on other people. We are all inter-connected. If I am exposed to coronavirus, and infected, I can unknowingly pass it to another person before I develop any symptoms. That person may be someone who is at a much higher risk of death than I am: my parent or grandparent, my neighbor, my coworker, my friend…
As discussed above, 4 out of 10 adult Americans have a condition that places them at high risk for serious complications from COVID-19. Lack of symptoms does not mean that you are not carrying the virus. Asymptomatic and pre-symptomatic people (who later go on to develop symptoms) appear to be playing a major role in the spread of SARS-CoV-2.
Some have talked about a strategy of letting the virus burn through a population to develop “herd im-munity” for COVID-19 without waiting for a vaccine to be available. Herd immunity is a condition in which most of a population is immune to an infectious disease. When enough people are immune, they are able to (most of the time) protect the rest of the “herd” that is not immune, as the chance that one of those who is not immune is exposed to someone with the infectious disease is low.
Epidemiologists agree that to reach herd immunity for COVID-19, likely at least 60-70% of the popula-tion would need to be immune. This means that, without a vaccine, over 200 million Americans would need to be infected with coronavirus, which would likely not take place until well into 2021. 200 million Americans infected with coronavirus could result in 500,000 to 1.6 million coronavirus deaths.
When thinking of herd immunity, it is also important to be aware that there are many unknowns with immunity to the virus that causes COVID-19. We don’t yet know if antibodies to the virus mean that a person is immune. If a person is immune, we don’t know how long that immunity lasts. We also don’t know if a person can get re-infected, and if so, if the re-infection could cause more severe illness than the original infection.
In a line of thinking related to herd immunity, some have suggested that we simply isolate all of the high-risk people and the rest of us can carry on as “normal.” This vision fails to realize how intercon-nected we all are. 24% of adults ages 55-64, and 21% of adults 65 and up live in multigenerational households. So do millions of younger medically vulnerable adults and children. How would we separate out all of these high-risk people from their lower-risk family members?
Even if we somehow were able to isolate high-risk people away from the rest of the population, it would be impossible to completely seal off the high-risk group from everyone else. If one infected person contacted the uninfected high-risk population, the virus would have the potential to spread like wildfire, exactly as we have already seen in nursing home settings.
Now, if you are able to get to low enough numbers of infected people, and have the ability to effectively test high numbers of people and quickly isolate the infected and any of their contacts, then you might be able to better control this spread. Many other countries are doing this.
This requires getting case numbers down low enough that they can be managed in this way. The best way that we know of to get case numbers low is by widespread “social distancing,” where enough peo-ple in a population stay far enough away from each other that the virus stops spreading. If we could all just freeze in place for two weeks, the virus would die out. It needs to spread from person to person to stay alive. Of course, freezing in place is not an option. “Social distancing” is the closest we can come to this.
The Washington Post has an interactive article that will run different simulations each time you click on it comparing methods. The extensive social distancing (fewer people moving around) method consistently works the best to bring case numbers down.
Many different countries around the world have been able to bring their daily case numbers down to very low levels. Basic actions including strict social distancing, travel restrictions, massive testing, and mask use can help achieve this. (Chen Shen and Yaneer Bar-Yam, COVID-19: How to win, New England Complex Systems Institute (April 5, 2020))
How Exactly Do We Catch this Virus?
In order to know how to best protect ourselves and our families, it is important to understand how we are most likely to contract this virus.
While it is good practice to continue to wipe down commonly used surfaces and wash hands frequently, the primary method of spread is close person-to-person interactions.
When an infected person talks, coughs, sneezes, or even breathes, droplets containing the virus are ex-pelled into the air, where they can land on a nearby person and infect them through their mouth, nose, eyes, or lungs. Tiny droplets, known as aerosols, can also carry the virus from an infected person into the air, where the virus can circulate for longer periods of time and be inhaled into the lungs via the nose or mouth by someone sitting far away from the infected person.
The CDC currently considers a high-risk exposure to be 15 minutes or more contact with someone less than 6 feet away. They do note that, when assessing risk, while shorter interactions are less likely to result in transmission, “symptoms and the type of interaction (e.g., did the infected person cough directly into the face of the exposed individual) remain important.”
Epidemiologist Dr. Osterholm explains, “While it has become a common recommendation that a six-foot distance is sufficient to eliminate the risk of inhaling infectious particles, we know that infectious aerosols can travel farther distances, particularly indoors.”
Cloth masks provide some protection, but because some infectious droplets and aerosols can escape around the sides of the mask and be inhaled by someone else, masks are not a replacement for social distancing measures. To be most effective, masks should be tight fitting and cover the entire mouth and at least halfway up the bridge of the nose. Masks are likely to be most helpful at times when you need to be in close physical proximity with someone who is not in your household, such as in the grocery store or pharmacy.
Dr. Osterholm says, “First, it cannot be overstated, that the most important thing someone can do to protect themselves from becoming infected with SARS-CoV-2 is to maintain as much distance as possi-ble from other people who you are not living with . . . masks may provide some benefit in reducing the risk of virus transmission, but . . . distancing remains the most important risk reduction action they can take.”
Unfortunately, mask wearing has become unnecessarily politicized in our country. While reading a recent online article about COVID-19, I was pleasantly surprised by commentor Billy Harris, who, rather than arguing back and forth about who was right, simply said, “I’m not a big mask guy, but I believe in simple courtesy and am sympathetic to the fears of others. So, when I go into a store, I wear a mask. No big deal.”
Let’s all aim for the simple courtesy and thoughtfulness for our neighbors that Billy Harris demonstrates, and wear a mask when we have to be out in public.
So, What Do I Do?
This is the point in the office visit where the patient turns to me and asks, “So what do you think I should do?” Or, sometimes, “What would you do?”
One thing I will emphasize before further discussion: Please do not delay going to the Emergency Department if needed. If you have an emergency, the safest thing you can do is get quickly evaluated and treated for that. If you have any concerns about being seen in person for non-emergent medical issues, please discuss these with your doctor. Many practices are offering some phone and video visits at this time.
Many people have questions and concerns about the safety of various activities at this time. Governor Northam has indicated that Virginia moves into Phase Three of re-opening July 1. This phase will al-low for up to 250 people to gather at events with social distancing measures.
As a physician friend of mine said, “This does not necessarily mean that it is safe; it just means that there is room for you in the ICU.”
There is no way I can address all potential activities or scenarios here, but hopefully I can offer some general advice that will be a helpful framework for thinking about these decisions.
- Consider wants and needs.
Both of my children attended Kindergarten at Brownsville Elementary. Among other very important lessons, they both learned then about something that we still talk about today (thank you, Mrs. Abell and Mrs. Davis!): wants and needs. Is this activity something that you need to do? Then let’s find the safest possible way for you to do it. Is this activity something that you want (but don’t need) to do? How much do you want to do it? Can it wait a little longer? Or is this something that is very important to you that cannot wait? Then let’s consider the risks, and if you still want to move ahead with this activity, we’ll try to find the safest possible way for you to do it.
- Consider risks.
Look at the risk in your community, both the current numbers and the trend of where the numbers are going. Look at your own risk factors for severe illness, and consider the risk factors of those in your household “bubble” that you are in close contact with. Also consider the possibility that you could un-knowingly infect someone else that you contact.
If there are people that you are bringing into your household “bubble,” it is important that everyone is able to be honest about what their potential exposures outside the household are, and that there is on-going communication about these exposures and each person’s comfort level with these.
- Managing risk
For an activity that you need to do, or those that you want to do (and have determined that the benefit outweighs the risk), then as much as possible, choose a way to do it that minimizes your risk.
A few things to think about:
It’s really pretty simple. Not necessarily easy, but simple.
The most effective way to stay safe is to continue social distancing measures to the greatest extent that you are able.
Some excellent, detailed information on various scenarios is contained in this blog post by biology professor Dr. Erin Bromage.
I also encourage you to talk with your own physician if you have specific questions about weighing the risks and benefits for your particular situation.
Please remember that our understanding of this virus is constantly changing and that some of these risk assessments may change as we learn more.
Some Good News
There is some good news, too. We know how to slow the spread of COVID-19. Social distancing works. Data by U.Va. estimates that more than 900,000 cases of COVID-19 have been avoided in Virginia due to social distancing measures.
U.Va.’s data shows that with the social distancing measures in place, the R0 in Virginia as a whole has dropped from 2.2 to below 1, and has remained below 1 since May 26. This means that, on average, each person in Virginia with coronavirus now spreads the virus to fewer than 1 other person. This is excellent news. If this continues, we can expect cases in Virginia to con-tinue to decrease further and further.
It is important to note that this modelling predicts that if we returned to pre-pandemic levels of non-socially distanced behavior, we could see increasing numbers of new cases, with a new peak in early July, but these predictions are not set in stone. They are changed by our actions now. If enough of us continue social distancing measures, we can expect cases in Virginia to continue to trend downward.
This has been a difficult time, for many reasons, for us as a country, and for many of us individually. We are living in a time of a global pandemic, economic crisis, and racial injustice. Many of us have felt anxious, sad, and angry. It can at times feel difficult to even know what to do to try to make things better.
Above all, please be kind to yourselves and each other. Stay home when you can; it will help protect not just you and your family, but also the vulnerable in our community. When you do go out, keep your dis-tance from others as best you can and wear a mask. Be compassionate when it seems to you that others are overly anxious or too careless about the coronavirus risk; we are all navigating a new world. Reach out to your neighbors, family members, friends, and offer support. We can get through this, together.