Ebola — The North Kivu province outbreak that we have been covering seemingly forever now has gone 41 days without a new case.  WHO officially considers this one closed (again).  Hopefully, the closure lasts longer than the previous one.  On the other side of the DRC, the Mbandaka outbreak is now up to 20 confirmed cases with 13 deaths.  Two of those cases were detected at travel checkpoints.  They have added three new vaccination rings as some of the new cases were not known contacts from previous ones, and contact tracing remains generally inadequate.  Further, the WHO notes “the unfortunate disappearance of several suspected cases into the community.”  That is suboptimal for containment.  They are vaccinating pretty liberally though.  However, with transmission clearly continuing outside of known contact chains, containment is unlikely in the near term.

Coronavirus–Another week of mixed data and mixed messages. 

–New cases in the US (as well as Brazil, Russia, much of Africa, Mexico etc.) continue to increase.  In part, this is because there is much more testing capacity and more and more people are getting tested.  But only in part.  As we have mentioned before, there is -wide- geographic spread in the new cases, which is to be expected in a country that spans a continent.  There are some bona fide hot spots.  Houston, in particular, is getting hammered and the healthcare system is starting to strain.  Arizona, Florida, and California are also all seeing steady increases to name a few others. 

Part of this is failure of the Great Memorial Day Experiment and the Kaiser Chiefs Greatest Hits Experiment.  But a big part also seems to be interruption of the initial phase of infection in many states, which never really got their peak infection before the entire country shut down.  They are playing catch up now as they re-open.  This is best illustrated at the following website:

https://rt.live/

Basically, Rt > 1 is an outbreak that is continuing to spread, as each sick person infects at least one other person.  Rt < 1 is an outbreak on its way out.  The best part of that link is that their Rt calculations now goes back three months, in 1 week, 1 month, 2 month and 3 month tabs. 

You should click all those tabs, and watch what happens with the individual states Rt at different time points.

Or at least click the 3 month, 2 month, and now.  You will note, generally speaking, that all the states showing good control now were all the ones with a breakout in March/April.  Two months ago (~ April) the entire nation was pretty locked down, and SARS-CoV-2 was running out of gas.  Now, all the states that were NOT in a major spread peak 3 months ago are largely the ones with spread now.  All the national lockdown appeared to do was delay their major spike in cases, while letting those areas already at their peak blunt that peak and recover.

Remember, Pandora’s Box is wide open.  The virus is out, and until herd immunity (or a wildly successful vaccine) is established, the virus will continue to spread.  Effective treatment eliminates the threat of healhcare collapse (again, the main threat of SARS-CoV-2 outside of those in high risk demographics), but does not stop the virus spreading so much.  “Flatten the curve” is predicated on s t r e t c h i n g the number of infections out over time so there are not so many so fast you run out of hospital beds.  But the same number of infections to herd immunity will need to happen. 

So as the initially less affected states re-opened, the simmering infection still had enough uninfected hosts available to it to re-ignite in some of these states.

Again, “second waves” will most likely be reignition at state/county/regional level.  That’s happening Beijing.  That’s happening in Victoria, Australia right now.  The US is not, and will not, be unique in this regard.  Even within states, geography has changed.  For example, the Big Easy was getting hammered like it was 5 hurricanes into a Boubon Street bar three months ago.  Louisiana’s new cases by and large are outside of New Orleans as the state is reopening.  New Orleans itself is likely at or near critical mass for herd immunity.

–Other perspective to keep in mind is the percent positive rate, or the number of positive tests versus the sheer number of tests being done.  Here is the United States (as a whole) percent positive rate:

https://coronavirus.jhu.edu/testing/individual-states (accessed 25 June 2020)

That little uptick in the blue line on the far right to 5.9% is the driver for the top line, nominal “NEW RECORD IN NEW CASES” headlines you are reading.  It is a smaller percentage than the ~25% positive rate in late March/early April when about half the US was hitting its peak and the national lock down started.  But it’s a smaller percentage of a MUCH, MUCH larger number of tests (the peach?  light pink? bars).  So it’s a higher nominal increase overall.  But it’s hard to see a spreading wave of coronavirus darkness in that.  That little tick higher is Memorial Day and Kaiser Chief Experiment failure, plus some states catching up to their first wave peak. 

–So is SARS-CoV-2 still spreading?  You betcha.  Gonna keep doing it too.  Some locales and regions will be a little hotter than others.  Frankly, depends in large part on how badly they have already been hit, and thus how close to herd immunity they are.  And we only have guesses about that.

–That said, and since this is another model, HUGE caveats about concluding too much from it, but this just came out and suggests surge in flu-like illness in March through April corresponds with SARS-CoV-2, and due to test volume limitations, may indicate a larger population has already been exposed.  Their projections are consistent with antibody data in New York, which helps, but again, makes assumption that ILI cases were untested SARS-CoV-2.  They also list other important limitations worth reading:

https://stm.sciencemag.org/content/early/2020/06/22/scitranslmed.abc1126

–I’m not sure there is such a thing anymore as getting a pandemic response “right.”  It really comes down to degree of damage mitigation.

Remember–perception of effectiveness is more important to “leaders” everywhere than actual effectiveness.  That perception can be enhanced by finding your favorite stat (in your favor) and saying “see?  At least we’re not those guys!”

That is the bark of the sheep dog.  Don’t become a rhinoceros.

–Also, bear in mind simple psychology.  It’s not that there are people out there rooting for the worst case, a coronavirus crisis without end.  Shared crisis is what binds a tribe more effectively than anything else.  When surveys have been done with soldiers coming back from war, that is the biggest adjustment difficulty they had.  While they were in country, under fire, they were united with purpose, and at high stakes.  That’s the “band of brothers” connection that turns up time and again among guys (and gals) who have served.  The come down from that is hard.  Veterans will rightly tell you war is absolute hell, and what scares them most is how much they miss it.  Not for the fear and the violence, but that unity of purpose where the self truly dissolves into action for a common good.  The mission is clear, the objective defined, the stakes high.  Same for a pandemic. 

Coming back from the war will be hard for some.

My best guess is that we are in the mid-game globally with SARS-CoV-2.  As we grind along to the late game, expect to see selected stats and findings and headlines that strike you as highly out of line.  Expect them, because that’s just the folks having a hard time coming down from the urgency and unified threat of a pandemic to the less urgent normal.  It will happen, but hopefully you can recognize it when it does.

–Another example of the psychology at play here.  Olympics this time.  They did a study once, looking to see which medalist, gold, silver, or bronze, was happiest one year after the games.  Across sports, the findings were the same.  So who is the happiest one year later?  1st, 2nd or 3rd place?

3rd place.

Yeah, they’re just pumped they made it onto the stand and got a medal.  That’s enough, and they also know what minor tweaks they might need to get to the next level.  They still have a clear, and clearly achievable goal.

2nd place is often drowned by perseveration in how close they came, but fell short.  The Super Bowl hangover, where the second place team often has a dismal season the following year, is a real thing.  Coulda’ shoulda’ woulda’ takes a huge toll.

1st place probably surprises you.  The challenge for gold medalist is similar to the pandemic comedown.  You had this clearly defined goal.  You rose to the challenge.  You achieved.  Got to the mountain top.  Won the contest, took the gold.  “What comes next?” is the question that gets the 1st place finisher.  “Is that it?” they wonder.  They expected it to be so different, but once the parade is over and the party in Vegas, well, even Wheaties moves on with its cover.  Even worse, that gold now becomes expectation every time you go out.  This is why dynasties and Michael Phelps are so rare.  Once you’ve met THE goal, feeling a little lost about the next goal is a common thing.

–I’ve mentioned this is by -far- the most attention any of my mass emails have ever gotten.  I can already tell you here’s me in the not especially distant future once coronavirus wraps and this new Ebola outbreak is contained:

–More on actual coronavirus data though.  The latest available data from the CDC suggests about 1.5 million positives in the US as of last week, with a little over 30,000 COVID-19 associated hospitalizations.  In the raw, that is a 2% hospitalization rate, and of those, 91% have an underlying severe illness (obesity, hypertension, diabetes and cardiovascular disease are most common).  Among the uncommon hospitalization of children, 53% have an underlying medical condition (asthma, obesity and unspecified neurologic condition most common).

Adjusted per 100,000 population, the standard epidemiologic measure, your overall chances of being hospitalized by COVID right now are ~1 in 1,000.

That’s before knowing if you are positive or not, and just your raw risk. 

-If positive-, again, based on the raw numbers (and there is probably a statistician or epidemiologist screaming into the void right now that I am oversimplifying this), your chances of needing the hospital are 2% +/- your age and underlying conditions. Little higher if you are a high risk group.  Lower if you are not.

–Growing evidence on how to best catch SARS-CoV-2.  The latest data suggests that risk from contaminated surfaces is pretty minimal (things like door handles and the like).  The best way to catch it is sustained close contact with lots of talking.  So, like in a packed pork processing plant, factory, dense cubicle farm, densely packed bar/club/party.  Those are likley your highest risks.  If you going to those, a mask is a really good idea.  Indoor dining at restaurants is probably a risk too, but mostly because you cannot both eat and keep your mask on–otherwise, your time on target is usually only about an hour versus your pork plant shift or all night EDM rager.

–Masks in general are still not a bad idea.  Yes, I know Dr. Fauci here in the US admitted to basically lying about effectiveness back in March, and is now out there trying to get everyone to please wear a mask.  And then going onto interviews bemoaning why Americans just “don’t seem to listen to science or experts.”  Well, the mirror would be a great place to start.  Even if the goal of lying about effectiveness in masks in March was to keep as many as possible available for healthcare workers, he pretty much sacrificed all of his credibility on that hill. 

–Again, another major lockdown just doesn’t seem in the cards, reading the temperature of the room.  We are all Sweden from here on in.  Might there be more success locally?  Hope so for Houston’s sake.  But the kind of quarantine we saw in March/April is unlikely to be enforceable going forward.  Just too many breaches of the public trust by those in leadership positions.

–Besides, I am old enough as a physician now to know that the best you can do is put the information honestly and consistently in front of people.  They are going to make their own decisions.  There is no use bemoaning people who just won’t listen to expert opinion, with deep understanding of a wide and well executed body of studies, literature and best practices behind them.

Trust me.  I know people who still smoke!

And not to pick on them.  Raise your hand if you have always, everywhere and always, done exactly what is recommended for best health.  You can’t–because our dietary guidelines have changed based on new evidence.  And you didn’t even follow those all the time even when that was what we thought was best.

–You don’t have to make it worse by clearly contradicting yourself though, Dr. Fauci, or making it clear that you are willing to lie to the public if you believe a greater good is achieved by it.  “Masks work, but we ask that they be prioritized for healthcare workers” was and is a much better way to have acted.  That almost certainly would have galvanized drives to make sure frontlne health care workers got as many masks as possible.  Instead, the lie undercut such efforts–why bother, if the doctor leading the pandemic response says they are not proven effective?

–Alright, I’ll get off my soap box now.

–You may have seen posts earlier this week about Apple and Google rolling out software updates that enable tracking for SARS-CoV-2 contact tracing.  Here is the best explanation of what is going on that I can find (at least, there is no obvious axe grinding here):  https://www.forbes.com/sites/daveywinder/2020/06/20/have-apple-and-google-suddenly-uploaded-a-covid-19-tracking-app-to-your-phone-android-iphone-exposure-notification-contact-tracing/#48b7ce7c6054

Basically, default setting appears to be “off” and is really only a capability to make actual tracking apps function if you decide to download one.

–I am not going to comment too much on this, other than to point out that as testing capacity increases, not all tests are created equal.  This article is worth a read:  https://www.fiercebiotech.com/medtech/as-problems-grow-abbott-s-fast-covid-19-test-fda-standards-are-under-fire

–Lastly, the think piece.  Short twitter thread:  https://twitter.com/CoveringDelta/status/1276132419557605377

–Your chances of catching Ebola are equivalent to the chances I win an Olympic gold medal.

–Your chances of catching SARS-CoV-2, in most places in the world, are equivalent to the chances I watch someone else win an Olympic gold medal. 

<Paladin>