COVID-19: Questions and Answers
Today is an unprecedented time in history, not just for the US, but the world. We are all experiencing a range of emotions that change on a daily basis. We all have questions, but at this time, no clear answers seem to be forthcoming. What answers we do come up with are not easy answers. They all come with limitations and shortcomings in some form or another which leaves a lot of people conflicted.
The purpose of this blog post is to give a brief overview for the lay person in the US regarding the current Coronavirus pandemic of 2020 with the information available as of March. I will write this in a question and answer format.
Q1: How many infected patients can we have nationally and locally in Manhattan, KS and manage without rationing care?
The numbers: possible scenarios
I have culled the population data from the census.gov website to obtain the age demographics for the US. Currently the American population is 327.2 million as of 2018. The American population above the age of 65 numbered 52,423,144 million. Below is a breakdown of the population by age with the number of fatalities based upon current mortality rates for COVID-19 found on https://www.worldometers.info/coronavirus/coronavirus-symptoms/.
Mortality Projected Deaths
Rate (%) from COVID-19
Age: 0-4 19,646,315 0
5-9 19,805,900 0
10-14 19,646,315 0.2 39,293
15-19 21,445,493 0.2 42,891
20-24 21,717,962 0.2 43,436
25-29 23,320,702 0.2 46,641
30-34 22,023,972 0.2 44,048
35-39 21,571,302 0.2 43,143
40-44 19,927,151 0.4 79,709
45-49 20,733,440 0.4 82,934
50-54 20,871,804 1.3 271,333
55-59 21,624,541 1.3 281,119
60-69 37,770,109 3.6 1,359,724
70-79 22,842,537 8 1,827,403
>80 12,473,289 14.8 1,846,047
Total deaths under age 60 974,547 Dead
Total deaths over age 60 5,033,174
Total US deaths: 6,007,721
Preliminary Mortality Data for COVID-19 according to the Chinese data as of February 11:
13.8% require hospitalization
4.7% severe requiring ICU/Ventilator
Based on US Census population data, at a rate of 13.8% of those infected requiring hospitalization, then the number of infected patients requiring hospitalization will be 45,153,600 if 100% of the population were to be infected. The total staffed hospital beds in the US is 924,107. The total requiring ICU/Ventilator Management will be 15,378,400 based on a 4.7% rate of COVID-19 infected patients that will require ventilator management if 100% of the population was infected. Based on a 2009 survey of AHA hospitals, U.S. acute care hospitals are estimated to own approximately 62,000 full-featured mechanical ventilators. Approximately 46% of these can be used to ventilate pediatric and neonatal patients. Older models, which are not full featured but may provide basic functions, add an additional 98,738 ventilators to the U.S. supply. For purposes of this blog, we will say that we have 164,000 ventilators at our disposal.
Ideally, our mitigation efforts would spread out and stagger the infections so that the demand at any one point in time goes down, which is the goal of flattening the curve. Based on the actively staffed hospital beds available of 924,107, we can have no more than 6,718,167 Americans infected of the 327.2 million and have enough beds available. Keep in mind that this math uses every available bed and does not include the number of beds used for any other illnesses. If we account for the occupancy rate, then with an average occupancy rate of hospital beds in 2017 at 65.9%, that would leave 315,120 beds available for COVID-19 patients. That would allow for only 2,283,478 patients to be infected at a point in time if we were to have the capacity to manage the 13.8% that would need to be hospitalized. Based on the estimated number of ventilators, we can have no more than 3,489,361 Americans infected as this will lead to 100% utilization of existing vents. This number does not account for the number used for existing non-COVID-19 respiratory illnesses. If we factor in that approximately 1/3 of ventilators are in daily use for non COVID-19 illnesses, then that would leave enough capacity to handle a population of 2,337,872 patients that are infected with COVID-19 if 4.7% of them will require ventilator management. Please keep in mind, these numbers also assume we have adequate staffing for every hospital bed, supplies, and those who can manage the vents.
In Manhattan, KS we have a local population of 55,489 per census.gov data. Manhattan has 70 hospital beds at our local community hospital. It has 12 ICU beds between the ICU and IMCU units. There is an additional 10 beds in the express unit that can be utilized if needed for a maximum ICU bed count of 22. There are normally 4 mechanical ventilators and 2 portable ventilators available. They currently have the ability to increase that to a total 18 vents if needed including the anesthesia machines and other machines on loan. So let’s do the math. The local hospital has 70 beds available, and with a national occupancy rate of 66% that leaves 23 beds available for COVID-19 patients. That gives us 167 active COVID-19 infections at a hospitalization rate of 13.8% that can be managed at existing capacity. If they can increase the ventilator capacity to 18, then that leaves a total of 383 people in Manhattan, KS that can be positive for COVID-19 at any one time and there still be enough ventilators available to manage the 4.7% that will require a ventilator, assuming all ventilators are available and not in use otherwise. There are other variables and each one further affects other downstream variables, so you can criticize the accuracy of the data all you want. The point is that we cannot afford to have a widespread concentrated outbreak and handle the number of patients that will end up needing hospital and/or ventilator care.
Obviously, by spreading this out as much as possible, we can lessen the demand and strain on our system. We can also save lives, as some patients that otherwise would have survived will not due to limitations in access. If the healthcare system is at or above capacity due to COVID-19, then rationing of care will happen. Those who need the ventilators for other issues will not have access. Additional lives will be affected and lost. The numbers I have mentioned above have numerous variables that affect the outcome. The point of the doing the math was to give everyone perspective on the magnitude of the problem and why it is more essential than ever before for all of us to come together.
Q2: What is the coronavirus and why the big deal?
A2: The coronavirus (COVID-19) is a novel mutation of a known respiratory virus in the Coronavirus family, the same family that SARS originated from. It originated in Wuhan, China with the first cluster of patients being linked to a wet market where live and dead animals are sold. By novel, we mean that it is new and therefore no one has any immunity to it, therefore all are susceptible to an acute infection.
Q3: What are the symptoms and should we be worried?
A3: The most common presentation after exposure is an asymptomatic incubation of around 5-7 days, during which an infected person will have little to no symptoms, but will be shedding the virus unknowingly. Once the acute infection becomes symptomatic, studies of hospitalized patients have found that about 83% to 98% of patients develop a fever, 76% to 82% develop a dry cough and 11% to 44% develop fatigue or muscle aches, according to a review study on COVID-19 published Feb. 28 in the journal JAMA. Other symptoms, including headache, sore throat, abdominal pain, and diarrhea, have been reported, but are less common. Some patients have even reported a loss of smell or change in taste. Congestion, sore throat, sneezing are not typical presentations and other diagnosis should be considered, such as influenza and or seasonal respiratory viruses which are also still very much active.
Q4: Why are we so worried if it is just a cold? Is it really that much worse than influenza?
A4: It appears that there is a mortality rate around 1% +/- depending on the country when averaged across all ages. The population most affected are those above the age of 70 with comorbid conditions such as heart failure, compromised lungs, or those with complications from diabetes. They appear to have a mortality rate greater than 8-10% at this time. Furthermore, COVID-19 leads to respiratory failure as the primary cause of death. This requires ventilator management, of which the US has approximately 164,000. We need to keep in mind that there is still a segment of the population that will have no risk factors and will be young, and will have severe symptoms requiring ventilator support and will lead to death for some, despite no obvious risk factors.
The COVID-19 is also a wild card in that there is little known about it at this point and what we do know is fluid and subject to change rapidly. We have only had a little time to get a crash course on the nature of this virus. Influenza has been known for a long time giving us the ability to accurately monitor and forecast infections. We have vaccines, we have treatments, and we have a comfort level with it, as it is a part of our lives. Currently, the CDC estimates that around 38-54 million have been infected this season leading to 17-24 million medical visits, 390,000-710,000 hospitalizations, and 23,000-59,000 deaths.
Presently, our understanding is that the COVID-19 is more contagious than influenza. It can spread via droplets but also via airborne transmission. The flu is primarily spread by droplets. The incubation period of COVID-19 where a person is spreading the virus but asymptomatic can be up to a week before the virus causes symptoms and for up to 4 weeks after infection. The influenza incubation period is on average around 2 days and a person will typically shed the virus for 24 hours before symptoms start. Therefore, the COVID-19 is much more contagious as people can spread it unknowingly for several days before becoming symptomatic.
Q5: Can we stop the spread of the virus?
A5: At this point, no. We can slow down the spread. The way to do that is social distancing or shelter in place. Our most effective defense at this time, is the keep people from spreading it to one another. This is why the somewhat draconian federal, state, and community isolation measures that we have seen have been put into place. These measures are our most effective way to limit the spread of this virus and save lives. Also, using increased personal hygiene practices and general hygiene practices, for example, washing hands, coughing into the elbow, wiping down all objects that you and/or the public come into contact with are essential. Limit touching your face. Oh, and did I mention that you need to wash your hands as if your life depends on it? It may. If even a minority of our population refuses to take this seriously, it will put us all at risk.
Q6: Why do I keep hearing about PPE (personal protective equipment) and N95 mask shortages?
A6: Currently, there are not enough masks and PPEs for healthcare providers to manage the predicted volume of sick patients and to test people of interest. Those providers are exposed. We already have a shortage of physicians, nurses, and other providers and every person we lose to quarantine, illness or worse is a further worsening of those uniquely trained and knowledgeable to provide essential care. It is vital that non-healthcare workers do not hoard the masks. They should be contacting the local health departments, hospitals, and clinics that will be exposed to the coronavirus and donating those masks accordingly. If this were a war, we would arm our soldiers with the guns and ammunition necessary to fight that war. We would not have non-soldiers hoarding the weapons and ammunition to the detriment of the soldiers actually fighting the war. If the soldiers do not have the ammunition, then that significantly decreases the effectiveness of the front line soldiers. Cloth Masks are not an effective tool for our front line workers. They are recommended only because we have no alternatives. They should be utilized by non-healthcare employed citizens, leaving the N95 masks to the workers in the line of fire. The issue is that the N95 and above masks will filter smaller and smaller particles effectively decreasing the risks of transmission. The cloth masks cannot filter micron sized particles, but they can limit the spread of droplets and so they can be effective for those who are infected limiting the amount of droplets they are exposing others to.
Q7: Why is it so difficult to test people?
A7: In the US, we currently do not have enough testing supplies. We currently have to limit or triage the tests that we run due to the restricted supply and capacity to run the tests that we do have. Most tests have to be evaluated at a lab and have a 3 day-7day turnaround time. At this time, most people will not qualify for testing due to the restrictions. By the time a community has established that the virus is being spread in the community, then they test only the sickest hospitalized patients. The real value of the testing is to test all people at the earliest sign of any possible respiratory symptoms. That allows us and them to know if they are contagious and to quarantine themselves. That will be a strong tool to help use limit the spread of the virus. That is why it is essential to get point of care tests into the hands of local clinics or ideally a centralized testing clinic. We need to be able to test early and test often, so that we can identify those asymptomatic individuals and quarantine them, limiting their ability to spread it at the local grocery store or other public access locations.
Q8: If we can’t stop the virus, and can only hope to slow it, wouldn’t it be better to just let it run its course?
A8: There are no easy answers. Ideally, the social isolation and quarantines will stop the spread of the virus and in time the pandemic is stopped in its tracks. The rate of new cases in China and South Korea is at a standstill, if the numbers are to be believed. The concern, is that as they open for business again and people go back to work, will it return? Will we have to limit domestic and international travel for months and possibly years? Realistically, the only way to halt the stop of the virus is for every country to do what South Korea has done which will put the world at a virtual standstill for months on end, even once the number of new cases starts decreasing globally. It is a losing proposition.
We have to weigh the lesser of two evils. We have incomplete data and therefore we and our leaders are trying to make the right decision with incomplete information. The default, therefore, is to place lives as the primary decider, which is why you see the decisions that are being made. Yes, there are restrictions upon our constitutional rights, but there is no avoiding that either way. One argument is that if we can slow the spread, we will flatten the curve. In other words, instead of the population of patients that need a ventilator all presenting to the hospital in a relatively short time span and overwhelming our existing capacity, we can spread them out to better manage them and provide care for a larger number over time. Italy is the case in point. They had a rapid rate new infections and the hospitals/ICUs were overwhelmed requiring them to ration care based on a patient’s age. Those not meeting the criteria for care have been left to their own devices, to either live or die. Are we prepared to do that? We may not have a choice. Time will tell. So, the argument is to socially isolate, shelter in place, and quarantine in the hopes of avoiding overrunning our ICUs and ventilator capacity. We live in a country that prides itself on sparing no expense to provide maximum care to even those who are terminal to honor individual autonomy and avoid any guilt or blame. We can all sleep well knowing that we did everything we could to stop, what is inevitable for some, from happening despite statistics and data showing the futility for most patients that are elderly with co-morbidities that already make them unlikely to wean off the vent. The average cost of an ICU stay requiring ventilator is around $10,000 per day.
Q9: Various people have made the argument that since those that end up on the ventilator and/or dying from COVID-19 will be the same regardless of when they get the infection, then why shut the country down?
A9: I would reference the above answer. The US, as it pertains to end of life care, is not willing to ration care or decide who qualifies for care, as we feel it is wrong to choose who lives and dies. We have enough data to calculate probabilities, but if there is even low probability of survival, there is a majority of the US that say to honor individual autonomy regardless of futility. We would see countless outliers that defied the odds used as a justification for why rationing care was wrong. The other more prescient reason to flatten curve is that it may buy time. Time to develop a vaccine. Time to develop a treatment. Time to increase ICU capacity and ventilator capacity. Tesla, Ford and other manufacturers are currently at work retooling their factories to produce ventilators and associated supplies and other manufacturers are working on increased manufacturing of PPEs. If that were to happen, then with every day we delay the spread of the virus, more and more lives will be saved. Unfortunately, vaccine efficacy data will not be available for probably 12 months, which puts us past the reasonable amount of time we can shut down the economy among other things. That leaves a possible effective treatment as our next best hope. We have no guarantee that one will be discovered in the near future, so again, how long are we prepared to shut things down. There is promising data for some antivirals and everyone has probably heard about hydroxychloroquine as a possible treatment. Reproducible results need to be replicated showing efficacy before we can make any recommendations. Stay tuned.
Q10: Is this our new normal?
A10: No. For the near future, at least into April/May, this will be our norm. At some point, we will have to get back to business. Right now, it is a day by day journey. We do not have enough information to best determine what path to take and when. We are still reacting to the virus and gathering information. At a certain point, we will have enough data that we will be in a better position to move forward, but for now we are in a holding pattern. I do feel that we will have more answers in 4-6 weeks at the latest.
Q11: Is this going to be a constant threat or seasonal or will it disappear?
A11: No one knows. Warm climates are also starting to have it spread to their borders. Will it be milder for them? Who knows? There is some preliminary data showing that it does not spread as effectively in warmer and more humid climates. Even so, this is unlikely to disappear. I suspect it will be present with us moving forward, hence the importance of a vaccine.
Hopefully, we will eventually develop immunity or a herd immunity that limits it. Once we make it past the initial onslaught, we should be able to proceed with minimal disruption to our lives, similar to how we manage influenza. Herd immunity basically means that when the enough of the general population develops immunity, then those who are still susceptible will have a decreased risk of becoming infected as the virus will not be able spread to as many or as fast.
Q12: If we get it, are we immune to it thereafter? Will it be like influenza (it slowly mutates leading to moderate vaccine and treatment efficacy), the measles (infection or vaccination leads to lifelong immunity), or the common cold (infection does not lead to immunity, leaving you susceptible to recurrent infections)?
A12: We have recent results showing that the virus does not appear to mutate like influenza, so there is optimism that a long term effective vaccine will be on the horizon. We also believe that once infected and recovered, patients will likely have long term immunity. Definitive answers will come in time.
To all citizens not on the front line of healthcare. Your most effect tool is to limit the spread of COVID-19 by social isolation and sheltering place. That is how you can best protect yourself and your families. Limit going into public for only essential items such as groceries and practice hygiene like you have never practiced it before. Only touch what you have to and try to clean and disinfect when and if able.
All non-healthcare workers need to donate any N95 masks that they have. Any nitrile gloves also. The healthcare workers that are on the front lines have to do the opposite of sheltering in place and have to go headfirst into the COVID-19 line of fire, exposing themselves daily by treating and testing those infected. They are the ones that need the masks. We cannot afford to have them go down. There is no one to replace them. They will be the ones caring for you and your family. Do not hoard essential medical supplies. Give those workers the weapons and ammunition they need to fight this enemy!