COVID-19 What to Make of the Numbers and Social Distancing

My daughter and I arrived home safely yesterday. We chose to drive from Naples up to Chicago. Gratefully my brother lives in Louisville, so we had a long day of driving Saturday and less on Sunday. Glad to be home safe and see my wife and boys. Given all the travel I’m going to social distance a bit more aggressively.
What to make of the numbers about COVID-19? They’re all over the place. Death rate data from COVID-19 ranges anywhere from less than 1% up to 3%. That’s a big difference. And rates of infection are up and down, too. Ohio estimates that it has over 100,000 cases, but less than 100 are confirmed. Unfortunately, when the facts are in flux, the information can be interpreted in different ways and fed to people with bias. As a consequence, what people believe may vary. This, unfortunately, has become politicized. I've had more than on acquaintance say to me, "Isn't this just a bad flu?"
So, if the numbers are uncertain, what can we believe? Is all of the social distancing and closing of sports, schools and restaurants needed? We at Harper Health say yes!
There’s a philosophical approach that we need to take. Ask yourself, do I accept that some of what we are doing may be overkill? Yes or no. Let’s say your answer is, “No. This is way over the top and what is being recommended is way over the top.” So as a consequence a community (a workplace, school, doctor’s office, etc.) doesn’t participate in efforts to stem the tide of infection and the impact ends up being low. Those who were skeptical will then say, “See. I was right. No big deal.” Now a different community says, “Yes, I’m okay with overkill” and does participate in disease reduction efforts. In this community death rates also end up low. In both situations, few people die. Isn’t this a win? What if the first group was wrong? A name I trust in this whole process is Anthony Fauci from the NIH who commented, I like it when people are thinking I’m overreacting because that means we’re doing it right.”  If he’s right people don’t get sick. If he’s wrong, people don’t get sick. Win-win. Do you want to be wrong on this?
But the consequences, doc! The economy, jobs, my 401K, all of it is being hit, and what if we’re wrong? What if we did all of this, sending the economy into recession for nothing? This is a fair point, so if the numbers seem all over the place what are we relying on in order to make these difficult decisions?
Here are a couple of stories that help me process whether we should lean on the side of overkill. First, the stories out of Italy are horrifying. Their current plan is to not put people over the age of 80 and those with multiple medical problems on ventilators. If they become very sick, they’ll get all the treatment possible, but not the level of the intensive care unit. Also, Dr. Meg is part of a Facebook doctor-mom group and there’s a neurologist in the group who is being enlisted in Italy to care for people on ventilators even though her training is in brain and nervous system disorders. She hasn’t done this work in over 20 years, but the ICU needs care providers. A third story comes out of our own backyards in Washington and New Jersey. Two doctors on the front lines of the epidemic are hospitalized and in critical condition after contracting the virus, one young and one older. At Holy Name Medical Center in Teaneck New Jersey there are 11 COVID-19 cases, all male between 28 and 48 years old. Six of the 11 are in the ICU. Three of the six in the ICU are healthcare workers. What town is next? What doctor is next? What patient is next? I don’t want it to be you, and I don’t want it to be me.
So I feel very strongly that the recommendations are appropriate and perhaps even too lax. There was partying for St. Patrick’s day in Chicago on Saturday. Thankfully Gov. Pritzker closed them before the real holiday tomorrow. I’ve seen YouTube videos of mad partying in Nashville. And a friend’s mother who lives in Florida had a St. Pat’s party over the weekend. “I’m sure everyone at the party would be fine if they caught the virus and died. We’ve all had a good life.” Yet, on their way out their use of the ventilator prevented my/your/our brother/mother/sister/wife from using it.
We need to take this social distancing thing seriously. The concept is based on the idea that the infection can only spread if you come into contact with people. The virus needs a human host. It doesn’t live in mosquitoes like malaria or in deer ticks like Lyme’s disease. If one person has it and spreads it to no one (R0 of zero for that person), that branch of the expansion of the virus ends. So, by isolating ourselves, we can neither give it to anyone if we have an early or mild case, nor can we get it from someone. And if we slow the spread, we flatten the curve.
We need to be within six feet of someone’s respiratory droplets that we then inhale OR we need to touch a surface where the virus has landed and then touch our face/nose/mouth. Once you have the virus, it takes about 5 days to develop symptoms of fever and dry cough. The illness doesn’t come on like a freight train, but is mild for the first week and then in some patients can get very severe.
How do you social distance? There are a number of resources that I’ve looked through. Unfortunately the CDC has not given particularly good guidance, forcing individual groups to make their own suggestions. So, here’s how I put it together:
1. Limit the number of people in your immediate orbit. Imagine a six foot circle around you. You need to give permission to let someone into that six feet circle. Do you know who they are? Do you know if they are SARS-CoV-2 free? Do they have any symptoms or are they at higher risk for any reason (travel for any reason, recent large group activities, time in endemic areas of Seattle, Boston or NYC...)? The moment you let someone in this six feet circle, you are at risk of them coughing or sneezing and transmitting the virus to you. The moment you enter someone else’s circle you do the same, putting them at risk. Even minimally symptomatic people can spread the virus. We’re just not sure how significant that risk of spread is.

• When you leave your home you take a risk of someone entering your circle

• When you shop at a grocery store, go to a restaurant, attend a movie there is a lot of risk of circle entry, but if everyone kept six feet of distance and surfaces remained disinfected, the risk of infection would be low. Do we have the discipline as a community to keep six feet of distance?

2. Don’t gather in groups. Obviously, if you have a six foot radius around you, getting into a large group would not be on your list of things to do. I would recommend NOT congregating AT ALL.

• Yesterday the CDC recommended banning groups of 50 or more for the next eight weeks. Why 50 people? There’s no magic to this number. It’s about odds (and a patient who read the first posting of this blog helped me fix my numbers! Thanks Todd!).  If 0.25% (1 in 400) of the population has infection with SARS-CoV-2, in a group of 50 people there is a 12% chance that one person in the group has it. I guess that risk is acceptable to the CDC. We don’t think the community prevalence is at 0.25% yet, thankfully, but if we don’t isolate it could get there, fast. And if it gets to 3% prevalence, in a group of 100 there is a 95% chance (80% in a group of 50) that one person has it and could spread it to others. What risk are we willing to bear?

• Today (3/16/2020) the White House dropped that recommendation to groups of 10 people at most. Again, all it takes is one of the ten to have it…

• Can your kids hang out with other kids? Anytime we let someone into our circle we put ourselves at risk. In Italy and China, as I understand it, there is complete family isolation with no interaction beyond families. My recommendation: for now keep it All in the Family. (A classic show for bingeing, highly rated on IMDB.)

• What about visiting older relatives? Get them an iPad and show them how to FaceTime. This virus is particularly deadly for those over 80 – an estimated 15% who are infected die

3. Keep your hands clean. Soap and water works better than alcohol-based hand sanitizer to kill the virus that you may have picked up after touching something. Why? The soap breaks up the wall of the virus and kills it. It doesn’t need to be anti-bacterial soap – any soap will do. Seems silly to explain hand washing, but here we go:

• Turn on the water to warm/hot

• Get your hands wet, keep the water going. Drought is our last worry right now

• Pump soap onto your hands or use a bar of soap to lather your hands

• Put down the bar of soap

• Continue to rub your hands together, in between your fingers, under your nails

• Rub hands together for 20 seconds at least. That’s Happy Birthday twice

• Rinse off your hands

• Grab a towel and towel try your hands fully

• Use the towel to shut off the water

• Use the towel to open the bathroom door. Toss the towel into the garbage

If there are blow dryers instead of towels (grrr):

• Use your elbow to turn off the water. Blow dry your hands. Keep tissues in your pocket and use a tissue to open the door. Or:

• Use your elbow to turn off the water. Blow dry your hands. Wait for someone to enter the bathroom and leave at that time. Or:

• Use your elbow to turn off the water. Blow dry your hands. Use your pinkie finger to open the door and sanitize your hand with hand sanitizer

All of this is likely to change as we move forward. San Francisco is telling people to shelter in place. How long until that is recommended here? Please take care. Please heed proper precautions. I hope we all can stem the tide and look back and say, “See. It wasn’t as bad as we thought it was going to be.”

It’s truly time we moved from “me” to “we”.

Please let us know if you have any questions, and please contact your provider if you have any symptoms. 

More to come.

Dr. Will