We’re On An Adventure

Rainbows everywhere

Today we did something crazy. We drove from Missoula, Montana to Eureka, Montana and back to give a friend a ride back to civilization from their family’s compound after they tested negative for COVID-19. What a great chance to show everyone this amazing place I live!

I did say rainbows

Beautiful Montana

These are all from today

I am blessed to live in a place of wide open spaces and the optical illusion that creates a bigger sky

Where glaciers collide with clouds

Flathead Lake is always a welcome sight

Flathead Lake is a gem

We hit a bit of rain on our way, but it eventually subsided.

As with any good Montana road trip you have to stop for the wildlife.

Don’t worry – they move eventually

You’d never believe this is one of the major shipping routes across the US border into British Columbia, now would you?

Nearing Eureka as it begins to get darker

Blue sky still visible at 9 PM? Not for long!

Near Trego, Montana the last bits of day find their way into this beautiful night

We managed to catch the sunset on our way in to town

As I’m pleased to share with you some of the magnificent clouds we witnessed about 15 miles south of the Canadian border at the port of Roosville

As we return from Eureka we see signs reminding us to social distance and stay close to home. Missoula County and Lincoln County both have 0 active cases. Our friend safely in tow, they are also high risk, have been isolating, and need to get to Missoula for a doctor appointment that cannot be done over a video chat.

Whitefish looks desolate. There’s no one on the roads here. It makes sense – Flathead County is among the hardest hit in the state – every case that’s been traceable has been connected to travel. Flathead County is where the airport for West Glacier and Whitefish is. We head south toward Kalispell.

So helpful

We stop in Kalispell to charge the car and use a disposable barrier for handling the charging cable. Charging will require a couple of hours.

It’s dark, so the pictures aren’t going to be very interesting for the rest of tonight. We will be safely back in Missoula soon.

And there’s your Montana road trip during this crazy time. The world is a mess. Stay safe – hold your family close.

Aversion to Masks? How Masks Make A Difference

Why Wear a Mask?

Source: https://www.maskssavelives.org/

An organization called Masks Save Lives is currently calling out a link between “low mask acceptance cultures” and how badly COVID-19 outbreaks are affecting these areas and their failures to flatten the curve once outbreaks began. Research potentially supports this division, a 2009 study in Australia found that the data could not be assessed for if cloth mask usage reduced seasonal infections in the public due to low compliance by participants.

The CDC now recommends wearing masks and numerous websites have come out with instructions on how to make a cloth one (here’s one!). However, is there something to the cultural divide? We’re going to look at the United States specifically (though the next Tweet is from the UK).

An example of the reaction someone gets going to the store wearing a mask in England – one of the countries accused of having an anti-mask culture by the organization.

Why Do People Not Wear Masks?

Social Acceptance

Mask acceptance is not as easy as mandates and public health advisories. Beyond the scientific and home care acceptance, it must not be seen as a threat. Previously the lack of compliance in the Australian study may have been related to an element of social acceptance, however this was not studied at that time. If someone is uncomfortable wearing a mask they won’t. One community that may feel this impact are ethnic and racial minorities in the United States. One 2010 study investigated the barriers to mask wearing among urban Hispanic households in cases of upper respiratory infection. The findings concluded that these communities required higher risk perception scores before adopting face mask usage. This lead the researchers to conclude that face masks are unlikely to be effective for this community in the case of seasonal or pandemic influenza like conditions. The participants voiced concerns about social acceptability of masks within their communities – if they would be viewed as the source of illness – while others mentioned potential embarrassment.

Many have long dealt with violence related to the use of masks. Assumptions related to suspicion of crime, gang activity, and other racial profiling can making wearing a mask uncomfortable.

Legality

In the state of Virginia it is illegal to wear masks in public, though after the CDC’s announcement the law no longer applies.

§ 18.2-422. Prohibition of wearing of masks in certain places; exceptions.

It shall be unlawful for any person over 16 years of age to, with the intent to conceal his identity, wear any mask, hood or other device whereby a substantial portion of the face is hidden or covered so as to conceal the identity of the wearer, to be or appear in any public place, or upon any private property in this Commonwealth without first having obtained from the owner or tenant thereof consent to do so in writing. However, the provisions of this section shall not apply to persons (i) wearing traditional holiday costumes; (ii) engaged in professions, trades, employment or other activities and wearing protective masks which are deemed necessary for the physical safety of the wearer or other persons; (iii) engaged in any bona fide theatrical production or masquerade ball; or (iv) wearing a mask, hood or other device for bona fide medical reasons upon (a) the advice of a licensed physician or osteopath and carrying on his person an affidavit from the physician or osteopath specifying the medical necessity for wearing the device and the date on which the wearing of the device will no longer be necessary and providing a brief description of the device, or (b) the declaration of a disaster or state of emergency by the Governor in response to a public health emergency where the emergency declaration expressly waives this section, defines the mask appropriate for the emergency, and provides for the duration of the waiver. The violation of any provisions of this section is a Class 6 felony.

Code 1950, §§ 18.1-364, 18.1-367; 1960, c. 358; 1975, cc. 14, 15; 1986, c. 19; 2010, cc. 262420; 2014, c. 167.

Modifications Needed

I was unable to find documentation online of how those with disabilities that inhibit the use of masks are handling the situation or even recommendations for these individuals on how to stay safe. If you find anything, please tell me.

In other cases we need to consider family caregivers, and children, both needing modifications and not. Many children struggle to wear masks, particularly infants and toddlers. The primary reason most experts encourage children to wear masks is to prevent them from giving it to others, rather than to prevent them from contracting the virus themselves. But the CDC still insists that all children over the age of 2 should be wearing a mask when they leave the house. I am looking for further resources – at this time I have heard about this problem from friends that are parents.

The American Academy of Pediatrics has released the following guidelines for masks and children with special health considerations:

-If you must go outside or to a place where you are not able to practice social distancing with an infant, cover the infant carrier with a blanket, which helps protect the baby, but still gives them the ability to breathe comfortably. Do not leave the blanket on the carrier in the car or at any time when the baby and carrier are not in direct view.  

-Children who are considered high-risk or severely immunocompromised are encouraged to wear an N95 mask to best protect themselves.  

-Families of children at higher risk are encouraged to use a standard surgical mask if they are sick to prevent the spread of illness to others.  

source: https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/masks-and-children-during-covid-19/

In terms of the minimum effectiveness and materials? An Experimental Study of Efficacy of Gauze Face Masks published in 1920 the researchers concluded that cloth masks had basic minimum requirements that had to be met in order for a mask to have a “restraining influence on the number of bacteria-laden droplets possible of inhalation”. Part of this involved a balance between the number of layers, thread count, and breathability. If the mask is too dense as a result of the layers and thread count then “breathing is difficult and leakage takes place around the edge of the mask”. That leakage of air is what they proposed caused the reductions in efficacy observed. Research such as this resulted in recommendations of a minimum of 300 thread count fabric still used today.

Cost Prohibitive / Unable to Obtain

We’ve talked about poverty before. This can impact obtaining supplies, time to make a mask, and many other life factors that are none of my business and we need to be understanding. Others are unable to sew or are unable to put a mask on for themselves (see “modifications” above).

Do Cloth Masks Really Help?

We began asking this question a long time ago. In a 1920 study on gauze masks looking retrospectively at the data from the 1918 influenza pandemic regarding the infections contracted by healthcare workers, authorities’ primary criticism was that the weave of the fabric was too loose. Though the study still concluded that masks did not demonstrate to have a degree of efficacy that would warrant their compulsory application during an epidemic, they argued that masks should not be abandoned entirely. I’ll leave it in their words:

Studies made in the Department of Morbidity Statistics of the California State Board of Health did not show any influence of the mask on the spread of influenza in those cities where it was compulsorily applied, and the Board was, therefore, compelled to adopt a policy of mask encouragement, but not of mask compulsion. Masks were made compulsory only under certain circumstances of known contact with the disease and it was left to individual communities to decide whether or not the masks should be universally worn.


The reason for this apparent failure of the mask was a subject for speculation among epidemiologists, for it had long been the belief of many of us that droplet borne infections should be easily controlled in this manner. The failure of the mask was a source of disappointment, for the first experiment in San Francisco was watched with interest with the expectation that if it proved feasible to enforce the regulation the desired result would be achieved. The reverse proved true. The masks, contrary to expectation, were worn cheerfully and universally, and also, contrary to expectation of what should follow under such circumstances, no effect on the epidemic curve was to be seen. Something was plainly wrong with our hypotheses. We felt inclined to explain the failure of the mask by faults in its application rather than by any basic error in the theory of its use. Consequently, Bulletin No. 31* of the Board of Health brought out the fact that where it was sought to control influenza by compulsory wearing of masks certain obstacles developed. These were:


First, the large number of improperly made masks that were used.

Second, faulty wearing of masks, which included the use of masks that. were too small, the covering of only the nose or only the mouth, smoking while wearing, etc.


Third, wearing masks at improper times. When applied compulsorily masks were universally worn in public, on the streets, in automobiles, etc., where they were not needed, but where arrest would follow if not worn, and they were very generally laid aside when the wearer was no longer subject to observation by the police, such as in private offices and small gatherings of all kinds. This type of gathering with the attendant social intercourse between friends, and office associates seems to afford particular facility for the transfer of the virus. If, as seems probable, the virus is droplet-borne, this form of contact, where people are conversing with one another, would, of course, be much more dangerous than crowd association of strangers, even under the circumstances of gathering in churches and theatres. We were not satisfied, however, with this seemingly perfectly satisfactory explanation. We felt it to be imperative, if the mask were not to be permanently discredited, that more definite information be obtained concerning its uses and limitations. If, as we believed, the gauze mask is useful as a protection against certain infections, it would be unfortunate if its uncontrolled application in influenza should result in prejudicing critical and scientific minds against it.

The American Journal Of Public Health.

A 2008 Study that came out in PLoS One found that wearing homemade cloth masks reduced hypothetical infections after spraying people with a simulated contagion.

A 2011 review of “Physical interventions to interrupt or reduce the spread of respiratory viruses” found that …

Respiratory virus spread can be reduced by hygienic measures (such as handwashing), especially around younger children. Frequent
handwashing can also reduce transmission from children to other household members. Implementing barriers to transmission, such
as isolation, and hygienic measures (wearing masks, gloves and gowns) can be effective in containing respiratory virus epidemics or in
hospital wards. The more expensive, irritating and uncomfortable N95 respirators might be superior to simple masks. It is unclear if
adding virucidals or antiseptics to normal handwashing with soap is more effective. There is insufficient evidence to support screening
at entry ports and social distancing as a method to reduce spread during epidemics.

…meaning that isolation, hygiene, and barriers like masks were effective.

On a lukewarm note, a 2013 study found that they were “better than nothing” against droplet transmission during an influenza pandemic.

Health Belief Models are one of the most mad scientist or the most Psy Ops things about public health. How do you get an entire population to do participate in something that will help be better for everyone else in the long run – like washing hands? In 2014, a literature review of cloth mask usage was published in the Singapore Medical Journal taking a different approach to the use of cloth masks in the context of a Health Belief Model.

A later 2015 study in BMJ Open found

Cloth masks resulted in significantly higher rates of infection than medical masks, and also performed worse than the control arm. The controls were HCWs who observed standard practice, which involved mask use in the majority, albeit with lower compliance than in the intervention arms. The control HCWs also used medical masks more often than cloth masks. When we analysed all mask-wearers including controls, the higher risk of cloth masks was seen for laboratory-confirmed respiratory viral infection.”

With such mixed reviews being published, why wouldn’t we be hesitant to recommend masks when they’re being advised as only a last resort?

When is a mask not a good idea?

Masks can lead to inhaling your own infectious droplets from a sinus infection and spread it to the rest of your airways.

Here’s an anecdote. I am having trouble finding papers to support this, but this is the current hypothesis my immunologist and I have as to how I got that month long pneumonia in March 2020.

I had a sinus infection and I was wearing a mask. Then, I aspirated droplets from my sinus infection leading to a lung infection. This lung infection eventually developed into a pneumonia. This is an instance of when a mask is not a good idea. Circumstances when you can aspirate your own droplets from a sinus infection or from an oral infection would be while exercising, crying, or dealing with temperature or humidity swings that would result in a runny nose.

Other people who should not wear masks? The CDC recommends against masks for anyone with breathing problems, such as shortness of breath, children under the age of 2, and “Anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance.”

TL;DR

  • Wear a cloth mask if you can and assume good intent for everyone wearing a mask. They aren’t doing anything suspicious. Don’t call the police.
  • Masks work more than nothing. Please wear them, but wear them smartly. They do not make up for poor hygiene practices.
  • Some people can’t afford the supplies to make cloth masks, or they need modifications for their unique needs, or they cannot make the mask themselves. There are resources for that.
  • Children’s masks need consideration based on your child’s needs.
  • Masks are not always a good idea. Inhaling your own droplets can lead to pneumonia not related to COVID-19.

Thank you for reading this. Without you I am shouting into an ether. If you enjoy and want me to write more of these please share this or comment below with what you would like to see me write next.

I started writing this article on 8 April, 2020 and stopped because I needed a break from writing about coronavirus related topics. I will be continuing to update this post-publication.

Recovery: If 1 million Americans get coronavirus, what will the recovery look like?

Success With Flattening the Curve

I posted this on twitter last night after the briefing.

Remember how we were projected to have 2.5 Million cases? We have reduced the projected number of infected Americans by 1.5 Million to only 1 Million. 1 Million is not great, but that’s a big change. That is called flattening the curve and everyone should be thinking that is really amazing (I know I am). They did not mention the number in the briefing (frustratingly). But forecasting has gotten a bad rep in the past.

For those who are math nerds – that’s a linear fit to 1,000,000 (switch from exponential), which some dude in the early 20th century proposed was when the growth in the number of reported influenza cases was hitting it’s predictable rounded peak forecasted the maximum cumulative cases (the limit). I’ve been trying to go through my notes to remember more about how this all works because I don’t remember the name of who came up with all of this and I’m trying to find the paper. I will update this and replace this rambling text when I do.

Recovery in the US

Recovery is not a guarantee that you will not get SARS-CoV-2 again. There are recorded cases of reinfection internationally. We do not have enough data to know if this is reactivation of latent virus or if this is true reinfection. That said, we are finally looking for asymptomatic, both recovered and not, individuals.

A vaccine would be able to address this by using adjuvants designed to induce helper T cell immunity in addition to antibody based immunity. Vaccines take time. Realistically a good vaccine will be on the market in March 2021 at the absolute earliest. Anything before that I will be floored if it has sufficient efficacy to help.

In New York City, 40-50% of patients experiencing severe acute respiratory distress will be placed on a ventilator. If recovery required a ventilator, the testimonies from survivors do not suggest a population able to return to the workforce tomorrow. Shortness of breath, weakness, and other long term effects of hypoxia threaten the be permanent disabilities in this portion of the population.

But what if you do have immunity? You’ll be able to test that. What if you’re one of the lucky ones? I guess that’s up to you.

We’re in this together.

source:https://coronavirus.1point3acres.com/en

At each of these state clusters there is at least one urban center that has the dominant reservoir population. Once movement between urban centers (New York -> Chicago -> Houston -> Miami -> Atlanta -> Boston -> Dallas -> L.A. -> San Francisco -> Chicago -> Orlando -> Pittsburgh -> (etc. etc. etc.)) stops then there will no longer be additions of infected individuals into the populations. This is why non-essential planes need to be grounded.

I live in Montana. I am so blessed. I want to make it clear that we still need to behave. It only takes 1 person to infect 10.

My family and people I love live in Washington, Idaho, Oregon, Montana, California, Texas, Alabama, Louisiana, Florida, Virginia, New York, New Jersey, Massachusetts, New Mexico, Arizona and Maine. I’m terrified for everyone.

We’re going to gradually come to a new normal. Ask me questions and I’ll eventually address them in updates on these original posts.

As a change of pace, I’m going to stop writing about the coronavirus for a while unless there’s something people specifically think of graphs or other things that would be useful questions to be answered in something new instead of an update. I still have a backlog of a couple posts that will still get done though.

I will be starting to write short stories and weird little memoir style posts so people can enjoy my writing separate from the reviews.

Thank you for reading. Without you this is a shout into the void.

Coronavirus US Curve Update: How’s That Flattening Going?

The start of April 2020 has been hard for the United States.

Forecasting Cumulative Case Totals

source: https://docs.google.com/spreadsheets/d/1c-wa_OpRaa0a3uzpZv_e7aA08ibALjDvB-asLZmFJv4/edit?usp=sharing

It is really cool to watch the things start to flatten. But is that flattening from New York City? Unlikely. As of 5 April 2020, we pushed the 500,000 milestone out to 6-7 of April from what was predicted to be 1 April 2020 based on the early spread. Most likely it’s being contained and squashed in small communities via quarantines successfully and that is preventing the further spread at this time. In 1918, this drive to reopen cities and lift restrictions resulted in second outbreaks in many cities.

Let coronavirus be eradicated from your small town.

Hot Spots

Update 5 April 2020:

Source: https://coronavirus.1point3acres.com/en try to keep in the back of your mind that the cases are concentrated mostly in one central hotspot right now.

I’m going to start breaking down the specifics for each state to develop forecasting. It sounds like coronavirus is going to be with us for a long time, so we might as well figure out a way to predict these ebbs and flows that accounts for human behavior as well. Part of each post will be a regular update showing how the forecast is changing. By seeing that our actions have impact maybe I can provide a bit of positive feedback for people that need encouragement.

If coronavirus is with us, that means it has found its reservoir population. This is bad. This means it hangs out in those people and does nothing except infect others until their body maybe figures out something is going on. West Nile Virus and Dengue Fever hang out in mosquitoes this way, kind of. It’s more complicated than that. This sounds like another post.

Social Distancing Score

I don’t agree with all of their measures and I will explain why I think they are only accurate in certain parts of the country in another post. That said, I do think that it is a useful tool for awareness and contemplation on the score.

Source: https://www.unacast.com/covid19/social-distancing-scoreboard

As of 5 April 2020 the United States is still struggling with the concept of social distancing and these example struggles are leading to serious consequences. Do I think the above scoring system makes sense? No. But it’s better than nothing and I will address each state individually over the coming weeks while updating the rest of these.

TL;DR

  • We’re watching the curve flatten nationally, but I hypothesize that this is actually the accumulated effect of rural areas and low exposure areas quarantining and eradicating COVID-19, not New York City.
  • In 1918, this drive to reopen cities and lift restrictions resulted in second outbreaks in many cities. Let coronavirus be eradicated from your home town before we reopen everything.
  • Social distancing is hard to measure and important to be aware of. I will discuss this more.
  • New York City is a visible hot spot and may have an undiagnosed reservoir population that is asymptomatic or minimally symptomatic. We need accurate testing.

Thank you to anyone reading this. These are shouts into a void without you.

How Behaviors Impact Coronavirus Spread & Confirmed Case Reporting

Part 1 – Introduction to Issues

This is a pretty loaded topic. Breaking this one up into several parts. In this post I’m addressing limitations to medical accessibility, such as uninsured rates, caregiving, and religious exemption from government advised or required disease control practices, such as social distancing. Let’s talk about human behavior and how that may impact the vulnerability of your location in the United States to coronavirus.

Accessibility, Uninsured Rates, and Alternative Medicine

Source: https://www.census.gov/data-tools/demo/sahie/#/?s_searchtype=s&s_agecat=1&s_statefips= You can play with this viewer too! Go play with census data and learn about the United States.

There are many reasons Americans are uninsured. Being uninsured will ultimately lead to limited access to healthcare. Due to decisions that were made regarding how to implement mandated healthcare, the poor were punished for not being able to afford exorbitantly priced healthcare. I don’t care who you blame for it not working. Point is, it didn’t, and now we’re sunk. You may notice a similarity between the map above and the maps in my previous post on the closure of rural hospitals and poverty. Texas and Oklahoma are currently set up to be the two of the hardest hit states by coronavirus because these are uninsured populations that feel they cannot seek already-limited healthcare (because hospitals closed). This means that they turn to alternative medicine at home and don’t call a doctor due to the cost. Alternative medicine, though potentially complementary (waiting on research), doesn’t involve providing ventilators to people drowning from their own viral lung inflammation. Alternative medicine doesn’t necessarily involve reporting confirmed cases to the state, either.

Luckily, telemedicine is slowly stepping up the game at reducing costs and improving accessibility, but until we have Point of Care testing that allows for mass screening that could be distributed to a population via the health department – good luck. The FDA still strictly prohibits self administered tests. This is one of the major outstanding limitations preventing telemedicine from serving our most underserved and vulnerable populations in the United States during this pandemic.

Religious Exemption

Source: http://childrenshealthcare.org/?page_id=24

Religious exemptions for medical care are a real thing. I know there are people reading this that are going to think, “but no one in their right mind is thinking that now!”

Oh honey, I wish I could say that was so. Let me first introduce you to What’s The Harm. Even without coronavirus, people are and will be dying due to lack of access to medical care in part because their families opt out via religious exemptions. When this is combined with alternative methods gone wrong and cultural factors, the vulnerability of this population is amplified by pre-existing public health issues.

Part of the states’ Stay At Home orders have meant the discontinuation of standard church gatherings and not everyone is taking it so well. Across the United States, churches are challenging these orders by stating that they are restricting freedom of religion. The continued in-person gatherings of worship services and other church functions result in COVID-19 outbreaks within communities. The Palmer Grove Baptist Church in Burke County, Georgia is one example from today, 31 March 2020. Another example: a choir practice when there were no positive cases reported in the county lead to an outbreak due to asymptomatic transmission. In Arkansas, California, Florida, Louisiana, Oklahoma, South Carolina, Tennessee, Texas, Washington, and Wisconsin, churches have risked or spread COVID-19 to members through gatherings or other church related events. As long as church closures are seen as a threat, these communities will be at higher risk for impacts from COVID-19.

I’ll be making a separate post dedicated to addressing the religious exemption issue in a culturally sensitive manner. Stay tuned for part 3.

Home Care For The Sick

One of the most wonderful things about America is that we are a country of caregivers. By acting as a caregivers we enter others’ homes or share homes with them to ensure their wellbeing. Remember that map from this other post on poverty and rural hospital closures?

When we care for the sick at home, a variety of other factors come into play that may delay or prevent access to medical intervention or reporting. Cultural norms around illness, including distrust of the medical system, preference for home care, and family caregiving will play their roles in the spread of COVID-19.

Source: https://www.cdc.gov/aging/caregiving/caregiver-brief.html

This means that children and older family members that do have symptoms may not have access to medical intervention, documentation, advice, or have sufficient care or separation from family members. While these deep-rooted beliefs come from a nurturing and caring place of love, it is important that cases at least be documented. These practices currently put families and communities at high risk of having the virus spread within them. While we do have recommendations for caregivers and home care instructions for coronavirus patients, they are not practical options, nor sufficient for the average family in America.

Home Burials

Source: https://www.romemonuments.com/home-burials – great website. Highly recommend reading more there!

In Part 2 – Home Burials and Funeral Industry

Thank you to anyone reading these commentaries and predictions. Without you I would be shouting into a void.

Is the US flattening the curve? Yes. Significantly? Who knows.

How do you describe that feeling of watching numbers climb and realizing that you’re watching in real time the most global example of what you’ve studied and taught your entire adult life?

Dread? Excitement? Existence?

When teaching about pandemics we teach students to look retrospectively at the numbers of those that have recovered versus those that have died. We make estimates on the numbers of those that were actually infected based on documentation available (or more recently – on documented confirmation). At about 6:00PM on 27 March 2020 twice as many people had died of covid-19 in the United States as have recovered. Seeing those numbers broke my heart for a moment, so I had to talk it out to myself somewhere.

https://coronavirus.1point3acres.com/en as of 6:26 PM MST 27 March 2020

It’s too early to call what it will look like in the United States in terms of our final numbers with covid-19. At this time these numbers are skewed by post-mortem testing and testing criteria that limits test accessibility to those already in need of medical intervention over home care.

Things might look scary, but don’t give up hope. Update 30 March 2020: and reporting started coming in of recoveries! Part of why this reporting may have been delayed is due to stringent testing criteria.

https://coronavirus.1point3acres.com/en as of 12:47 AM MST 30 March 2020. The criteria most are going by: 2 negative covid-19 swabs with a minimum of 24 hours separation.

The reason for this standard is that there is a very high false negative rate with the rt-PCR based test. If anything goes wrong along the way – say there’s a bad reagent, too low of a sample of viral particles, or something goes wrong that invalidates the test it will come back negative. This is the bane of every graduate student that has ever done rt-PCR. They will tell you their horror stories, especially if they were from poorly funded labs.

For some additional hope.

There’s this amazing power of graphs. We can look at growth of reported cases overtime to project the number of cumulative reported cases in the United States in the future.

I started keeping these to track the projection if we stayed on an exponential number of cases reported (aware of typo – did not plan on using this graph for anything originally)

Even as we have expanded albeit limited testing across the United States the overall rate of growth of total cumulative cases is slowing. While this hope is based on very limited data, could it be that we may actually be flattening the curve?

Equation is changing – are we flattening? I’m not sure. We added a zero. [Does some math]. I don’t know if that’s significant yet.

We’re able to see the slope change as the day to day numbers change. Thus, we can see when our efforts are working. (See below)

Source: https://coronavirus.1point3acres.com/en has the ability to build graphs showing how the US has slowed growth from 28% to 25%. That 3% isn’t much, but it’s something.
Source https://coronavirus.1point3acres.com/en But remember that our reporting is primarily coming from one place right now. Go to the website and visit this graph – it’s actually a movie!

This is part of why we need accurate reporting above anything else. The numbers that only require home care matter. In order to accurately understanding the danger of a disease we have to know how many people have it and are acting as asymptomatic or low symptomatic carriers. This influences anticipatory healthcare planning decisions for patients and facilities. I will address this a bit more later in regards to the limitations of cultural understanding around death, dying, and disease.

Update 30 March 2020: Exciting New Graph! If we start looking at the growth in the number of reported cases since improved surveillance across the United States started around March 19th – Yes, the US is kind of flattening the curve. But not enough. We’re also not far enough in to predict the peak.

We can be hopeful. As of 30 March 2020 we were set to diagnose our 500,000th case on 4 April, 2020. Flattening the curve is succeeding in different parts of the country. I will be addressing this in a new post. As a brief update as of 12:01AM 1 April, 2020, we have moved that projection out to 5 April, 2020. My model is limited by not knowing what the current daily max testing capacity of the United States is yet.

Update 5 April 2020:

Hey, look! We didn’t hit 500,000 cases. That’s incredibly comforting and is a fantastic sign. That said, we still have a backlog of COVID-19 tests, an untested positive population acting as a reservoir to continue infecting our healthy population, and we have no control over this. At this point, it is believed that SARS-CoV-2 will become a seasonal illness in the United States.

Source: Same as before

Remember how I said before that the 500,000th case had been pushed out to 5th April? Now, that’s 6th April, 2020 if only looking at the cumulative cases since the 15,000th case in the United States. What if we look at since 23 March? On this day we had approximately 46,000 confirmed cases, with the next day climbing to 55,000 confirmed cases. This is the date we should look at to consider since 50,000 cases reported.

Source: same as before

It’s not changing. There’s enough growth in of confirmed cases in parts of the country that any flattening is being overwhelmed right now. America’s current check up isn’t doing so hot.

A website for further seeing how your area is doing with flattening the curve. It is grading the United States with a D, and I agree.

PPE Shortages

It’s not the fault of our healthcare workers and everyone needs to show gratitude. The United States is facing extreme PPE shortages, resulting in healthcare workers being put at risk for infection and at risk for being vectors of covid-19. Hospital acquired infections have long been a problem in the US due to poor hygiene practices among staff and invasive devices used in hospital settings such as catheters, PICC lines, and IVs. While this has been combatted over recent years by the installation of improved educational programs and the implementation of disease control specialist positions in hospitals and clinics, these measures are useless without sufficient PPE. Washing hands and hand sanitization does only so much. We dedicate a lot of research time and money to this topic.

Diagnostic Testing Has Barriers

Point of Care rapid testing is a luxury afforded us over the past ten years (and toward the end of the 20th century) for strep throat, influenza, drug screenings, and other common “ailments” that bring you in to say hello to someone like me (only using quotes because I included drug screenings). The fact that we have this soon to be available for the coronavirus at all is incredible. Not only will this help with disease surveillance, but we have the ability to accurately study a pandemic in real time on a scale like never before. We could have the ability to intervene and institute true quarantine measures assuming we roll out extensive Point of Care screening for everyone.

But until then, can I even trust this data?

Rituals Around Disease, Death & Dying Complicate Things

How many people are dying at home untested? Remember that across America we have incredibly diverse customs about death and dying.

I recently spoke with friends in New York City and she mentioned that she knew members of certain cultural communities that though they were symptomatic were not getting tested. Part of why this happens is because of cultural beliefs around illness and dying. It’s going to be scary and everyone is reacting in ways that may deter them from getting tested. This will limit our surveillance and will also result in transmission within communities.

In the American South (where I’m from) families conduct home hospice even during severe illness out of pride and the cost of healthcare. Once the family member has died they will contact the local mortician. While it might no longer be legal to do home embalming and many states have prevented home burials, this has never stopped families from caring for the dead. Caring for the ones we love as a final act is one of the most essential acts as a family member that is often robbed of Americans elsewhere across the United States. In twenty to fifty years will we need to do go all paleovirology/anthrovirology (actual fields!) on disinterred bodies to get the actual numbers? Or will we go the route of China with incinerating covid-19 presumed bodies without testing? Will we go the route of the US during 1918? Will we burn it all?

Another thing to consider with any pandemic is how the rituals around death in the home contribute to the spread of a disease. This paper regarding the Ebola pandemic addresses why it is important to understand how we culturally handle death in times of pandemic in order to appropriately control spread.

Future Questions We Will Hopefully Answer:

As we look into ways to protect our healthcare workers with limited PPE we should be reminded that there are other ways we control the spread of disease.

Are healthcare workers on PReP faring better?

Many of the antivirals in PReP and PeP are being tested in the treatment of covid-19. Healthcare workers in Emergency Medicine have recently started turning to PReP and PeP to prevent the spread of HIV as a result of blood born pathogen exposure. Are these healthcare workers faring better than those not on PReP? Only time will tell since the number of workers on PReP reporting is still rather low.

What percent of the population needs to participate in social distancing in order to flatten the curve?

There’s isn’t actually an exact percent. What’s critical is that those at highest risk of being effective vectors for covid-19 during the transmission period of infection while shedding virus are able to infect as few other people as possible. This is a complicated question I’ve broken down into a couple parts.

Who actually needs to be on a stay-at-home order / essential workers only order for us to flatten the curve?

Go Fill Out Your Damn Census So I Have A Better Map

On the U.S. Census map above population density is shown in dark areas. Are you in that darker half? Stay. The 🦆 Home unless you are an essential worker.

Are you NOT in the darker half? Then you should be worried if you hear that there’s community transmission in your county. At that point practice social-distancing.

But you’re not out of the woods yet my friends. I have some more criteria for you:

How far away does your closest neighbor live? If you live in an apartment building – you should stay home. Live out in the country? Congratulations you lucky son of a gun! We’ve shown those city slickers that living in the underserved parts of America with crappy, dying economies that have been sputtering out and suffering at the hands of a global economy and evil corporations ain’t so bad, now is it? Or is it.

How far away is the closest interstate, highway, airport, train station, and other means of connection? Ever go to the gas station close to those things? May want to rethink that. Those are going to be your highest risk areas.

There’s a certain percentage of the population that can’t participate in the Stay at Home orders. It’s not their faults and they should be treated with the utmost kindness. They are taking huge risks. If you are a member of this population there are ways to assess how high risk your workplace is (if you’re interested). The actions of everyone else helps to make up for that by creating distance and reducing the number of people available for transmission at all. I know that’s a little messed up, but that is part of the theory behind it.

Source: https://www.census.gov/library/visualizations/interactive/2014-2018-median-age-by-county.html#

What is the median age of your area? Serious question though. Also, how old are you? Yes, this disease is affecting young people and those with conditions that make them more vulnerable. But I want you think about what kind of threat you are posing to the other people in your area by being a vector. If you live in a dark blue area, even if there hasn’t been a reported case in your county yet – staying home or social distancing is protecting this vulnerable population. You don’t want to have helped transmit the first.

source: https://www.unacast.com/covid19/social-distancing-scoreboard

(Update 5 April 2020) What Is Your Social Distancing Score?

You have thought about population density. You have thought about your median age group and how that plays into susceptibility of your area. The actions of those around you also put you at risk. In the flattening the curve check ups on New York, Pennsylvania, and New Jersey I talk about how important social distancing is right now and how big of an impact it is going to have on what we see in the future, such as the one vs. two peaks in New Jersey. But remember that not everywhere can social distance. Pay attention to the areas graded “F” as we address poverty below and in this post here.

Source: https://www.census.gov/library/visualizations/2019/comm/family-gatherings.html Do you live in a multigenerational household or live close by to family and see each other often?

Do you live in a multigenerational household or live close by to family? Do you see them often?

You absolutely need to be trying to stay home. These stay at home orders are critical to you. Illnesses like this can spread through families like wildfire. We love our families, right? Keep our families safe. If you are an essential business employee, it is even more important that you protect your family and isolate from them if possible. In many cases there is caregiving. This is addressed more in this post.

Source: https://www.census.gov/library/visualizations/interactive/2014-2018-poverty-rate-by-county.html#

Do you live in an area that is severely impoverished?

I hate asking this question because it is loaded. Click here for further reading on an additional opinion regarding race and healthcare inequality relating to poverty. Problems with the wealth and resource gaps in America demonstrates the huge gap between the way we treat people and I’m from a deep blue dot on the Chesapeake Bay where those resources aren’t available.

Disease outbreaks are worse in areas where poverty is not appropriately addressed. If you live in an area like this, you need to take stay at home orders seriously and the problem is, you can’t. And it’s not your fault. Our government and humanity are failing you.

I made a new post to address this more. Point is: stay home if you can, but be compassionate with yourself if you can’t.

What is determined to be essential and how do they determine what percentage of the workforce can be considered essential?

Oh. See, here’s the fun part. They don’t. They think of essential services, not the total number of employees this prevents from participating in social distancing. The state governments will figure out why this is really really dumb pretty fast, especially since many are now seeing hiring booms in those fields (like gas stations and weed delivery). I’m not an economist or a business person. People need to eat. This will be a strain on efforts that has to be monitored.

If people are interested in hearing me rant about the topics I’m actually an “expert” (by degrees and academic research/teaching background only) in let me know. If you are I’ll actually go back and edit this rant and dress it up a bit.

Thank you to anyone reading this. Without you this is just a shout into the ether.