What do the next few months look like?

Updated: May 8

Go grab a bigger glass.

To get to what every parent wants to know right now.

Yesterday afternoon, the Governor of California announced that schools will not re-open their physical campuses for the remainder of the school year. I expect that we, in MA, will announce the same plan in the coming weeks.

We have not responded swiftly or aggressively enough, and in order to avoid the overload of our healthcare system we have to remain safely tucked away in our homes for quite a while. Experts say, at least 10 weeks.

I read an article today that may help you conceptualize our current status. The author described the USA as being on a boat in the middle of the Ocean. Our boat sinks and we must get into a life raft and make our way to the shore. The shore being the point of where life is back to normal. His estimate, was that it will take 12-18 months to get to shore, but, right now we are still swimming to the life raft.

Everything we are doing now as a society is to protect our healthcare system from being overloaded. Stopping unneeded deaths as a result of rationing of healthcare due to lack of resources. The job of the "flattening of the curve", a very important job, is to buy us time to build capacity in our hospitals, get enough PPE to the people that need it, find a treatment for our sickest, and build a massive testing system. Unfortunately, flattening the curve is not a solution to end of this pandemic, it just gets us to the life raft.

We will have made it into the life raft when we see the number of daily cases in our State, and across the USA, peak and then decline. But cases must peak and decline despite massive increases in testing. We have done a herculean job in testing improvement nationally; from only 1000 tests/day (1st March) to 6000 (mid March), to 110,000 tests on March 25th. But, we have been stuck at that level for a week.

It appears we have saturated our lab capacity for testing in the short term, and our daily infection cases are still rising. We need millions of tests, per day, and there is not a clear path to get to that testing level. I am hopeful that we will engineer and manufacture our way out of that problem.

The next 4 weeks are going to be rough. Yesterday it was announced that there were outbreaks in 48 nursing homes in Georgia, and in more than 30 aged cared facilities in Louisiana. More than 1000 first responder in NYC are infected and isolated. The emerging clusters in Michigan and Florida. The outbreak on the US Aircraft Carrier. It will continue to come at us non-stop. We will all need to unplug.

Closer to home, our confirmed cases of COVID-19 in Massachusetts are doubling every 3.2 days. There is some evidence that daily cases are plateauing, but the data is really noisy and our rate of testing has unfortunately decreased over the past 7 days (from 6k test/day to 4k/tests a day). So 'flat' new infections per day (orange), with decreased testing per day (blue), would suggest the virus is still actively spreading in the our state. Hopefully, the actions the State put in place a few weeks ago start to show in the data soon.

How is it still spreading in MA? obviously within households. But also in the community from those trips to the store, the quick visit with a friend, or more worryingly, spreading from interactions in our essential workforce. If new cases don't flatten soon, there may be enhanced social distancing measures applied to reel in the increase.

Flattening and declining daily numbers just gets us into the life raft. We have lowered the risk of harm to us by reaching the raft, but if we get out, we are back in the exact same situation as we were before: A naïve population and a virus that loves to use as a breeding ground. If we stop these social distancing measures, and even 1 unknown infected person exists, the epidemic starts again.

So the States have a plan to get us in the life raft: stay at home. But as a country, and it needs to be country wide, there is no articulated plan for how we spend our time while paddling the raft to shore.

At least we know what the shore looks like; it's when 60% of our population becomes immune, through natural infection or a vaccine.

But we do not know if, or when, a vaccine can be developed. We are already bypassing many of the hurdles of vaccine safety testing, like bypassing animal safety and efficacy studies to get product leads into humans quickly. As a person who makes vaccines, this worries me.

It usually takes 1-3 years in the lab, and 2-5 years of human clinical studies to get a vaccine to market. Most vaccines fail at the bench. Luckily, there are 40+ vaccines strategies being trialed by BioPharma and academia, and we only need one to work! But when you hear people say 12-18 months for a vaccine, this is paddling the raft at full speed and there are some corners being cut. We also need to work out a way to manufacture, deliver, and administer more than 200 million doses of a vaccine to the US population. Needless to say, there are some scientific, engineering, and policy challenges ahead to get us all to the shore.

In the mean time, we are in this life raft together (but at appropriate distances). Some prominent epidemiologists are suggesting that after being in 'stay-at-home' situation for 10-12 weeks to flatten the curve, we may be able to get out of the raft and go for swim. Resume some form of normal life until the prevalence of infection in society increases again to a predetermined 'trigger-point' (based on the number of hospital beds available). When that trigger is reached, we will be back in a stay-at-home situation until the hospital beds empty. We then re-emerge, and repeat this over and over again until we make it to shore (60% of us immune from natural infection or a vaccine).

We could speed the trip up (~4 months), by following the approach of the President of Belarus, Alexander Lukashenko, who said "better to die standing than live on your knees". He has taken a more relaxed approach to his country's response to this pandemic and is just going to let the virus do its thing in his 9.5 million citizens. It is estimated that 200,000 of his citizens will die with his approach. Needless to say, the countries surrounding Belarus have closed their borders.

Rather than this approach, we can improve the quality of the voyage to shore by coming up with better treatments and testing.

Treatments: We need to dump $$$ into research to test every drug that has been made for efficacy at targeting this virus. There are more than 100 currently being tested. Treatments rarely get us to shore faster, but they make the trip easier. Allow us to go for longer swims. As an example, mid last century, improved healthcare helped to reduce the number of people dying from measles, but the number if people getting sick from the measles virus remained stubbornly high. Only when the vaccine came along in 1963 did the incidence of measles decline in the community. In contrast, Scarlet Fever did not require a vaccine, just a better treatment (antibiotics)! So what we can hope for is a treatment that can, at a minimum, improve the outcomes for the most serious COVID-19 patients, and at best, be something we may all take prophylactically to stop infection in its tracks. I am certain that the first will be found, and I wish for the later. Advances in this area could substantial improve the quality of the voyage to shore.

Testing: While we are flattening the curve, we could also massively expand testing capabilities and start to recruit a workforce for contact tracing. If we test millions of people per day, we can find those infected and isolate them. Then perform contact tracing on everyone they encountered in the previous 14 days, and quarantine them. By doing this, only the infected, or potentially infected, are subject to restricted movement. This is the approach that Germany is proposing when they flatten their curve.

To close on a positive note and this could be big. Iceland is leading the way with COVID-19 testing. As of Tuesday, Iceland has tested 5% of their population for the virus (for reference we have tested 0.3% of our population). They have found that approximately 1% of those people tested so far are infected, and 50% of those infected have no symptoms or develop very mild symptoms. This was supported by a second study that showed in households with an infected person, roughly 10% of the people in the house were infected and didn't know.

This could mean that 3-4 million people in the USA already have the virus and are recovering with little to no disease, and it also means we are closer to the shore than we think.

This too, shall pass

This is an outstanding article.

About the author

Erin S. Bromage, Ph.D., is an Associate Professor of Biology at the University of Massachusetts Dartmouth. Dr. Bromage graduated from the School of Veterinary and Biomedical Sciences James Cook University, Australia where his research focused on the epidemiology of, and immunity to, infectious disease in animals. His Post-Doctoral training was at the College of William and Mary, Virginia Institute of Marine Science in the Comparative Immunology Laboratory of late Dr. Stephen Kaattari.

Dr. Bromage’s research focuses on the evolution of the immune system, the immunological mechanisms responsible for protection from infectious disease, and the design and use of vaccines to control infectious disease in animals. He also focuses on designing diagnostic tools to detect biological and chemical threats in the environment in real-time.

Dr. Bromage joined the Faculty of the University of Massachusetts Dartmouth in 2007 where he teaches courses in Immunology and Infectious disease, including a course this semester on the Ecology of Infectious Disease which focused on the emerging SARS-CoV2 outbreak in China.


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