COVID-19: Breaking Good or Breaking Bad?

I've been struggling with this article and I realized it is because we are at a breakpoint. The data doesn't yet reveal which way things will break. Things are currently breaking to the good. Cases are down. Over the four months since the first confirmed case in the US was reported, we've learned a lot about how to control the spread of the coronavirus. We've learned that #stayhome worked, saving between 25,000 and 80,000 lives. Even better, we've learned a lot of ways to keep the virus on the decline without having to shut everything down -- I'll share more about this research in a moment. Yet, for all that we've learned, there is a risk that too many people won't apply our learning and things could break bad. Breaking bad would mean a second wave that could be worse than the first.

Let me unpack the good and bad scenarios, and how to track which path we are on.

A Good Break In The COVID Trend -- And A Relatively Easy Way To Sustain It.

The US continues to see declines in almost every state in terms of new COVID-19 cases. The US is now down to 12% growth over 7 days prior (see chart above). Death rates, which lag cases by about two weeks, are also showing a similar decline. The rate of decline is not as fast as what South Korea or Italy achieved. Nonetheless, the rate of transmission in the US has been below the R0 of 1.0, which means the virus is burning out. (Here is a quick explanation of R0).

We accomplished this drop in transmission in a an extremely primitive manner by sheltering in place -- the same way viruses have been slowed since the middle ages. But this is hardly the middle ages and our economic system took an unprecedented hit. As data on the virus has accumulated, we've learned there are other tactics that can keep the virus down that don't require us going medieval.

Specifically, A path to avoid a second wave involves relatively easy changes to behaviors: wearing masks, washing hands, avoiding high risk indoor activities and keeping our distance. High risk indoor activities are places where people are packed closely together and there is higher aerosolized output - sneezing, loud talking, shouting, singing, cheering. Case tracing shows outbreaks in call centers, restaurants, bars, conferences, choir practice, church, and indoor sporting events, for example. These produce higher aerosolized output compared to silence or quiet talking. A library should be safer than a choir room or indoor sporting event packed with cheering fans. Even safer would be reading a book outside, several feet from anyone else. Safer still, listening to an audiobook while walking on an outside trail, only occasionally and briefly passing other people.

I've run the data through my models, and if about 80 percent of Americans wear masks, wash hands and avoid high risk indoor activities, it can accomplish the same thing as a vaccine or herd immunity in terms of slowing the spread and avoiding a second wave of infections and deaths. Granted, immunity from vaccine or COVID-19 recovery does more than just slow the virus from spreading -- it gives those with immunity confidence to return to activities such as indoor sporting events, choir practice, etc. But it is conceivable to have a functioning economy with masks.

One can imagine a sign in a business, right next to the "No Shoes, No Shirt, No Service," that says, "No Mask, No Entry." The vast majority of businesses can adapt and succeed in a mask wearing economy. It is relatively easy for citizens to adopt these new behaviors for the betterment of everyone. The US might have avoided much of the cases and deaths had we done what Singapore did in on January 30th, and issued four masks to every household. Instead, governments in the US funded this advertisements:

On April 3rd, President Donald Trump shared CDC guidelines to wear a mask. Unfortunately, he undercut the messages as he explained why he won't wear one. More and more leaders are wearing masks, and most everyone I saw today, in my quick social distanced run through the store had a mask on. Fortunately, today, we are seeing ads like this one, that send the right message.

I say relatively easy to stay on this downward trend because, really, how hard is it to wear a mask when we go out the door? How hard is it to wash our hands for twenty seconds every few hours when we are out and about? How hard is it for us to understand what types of activities put us in greater indoor contact with aerosolized germs -- and to decide not to do them?

Yet, how easy is it to get 80% of Americans to do anything? Staying on the downward trajectory should be easy, but it is not guaranteed.

Breaking Bad -- Getting Through The Coronavirus The Hard Way

The virus is in decline, but it is a slow decline. That means there will be thousands of infected individuals amongst us for several months. We are at a break point where we could continue to see a decline -- which would be good, or we could see the rate of growth pick up pace and exceeds an R0 of 1.0, which will be bad. Exceeding R0 of 1.0 will produce a second wave, with more infections and deaths.

My Forecast 1.0 expected a second wave -- but I created that Forecast at in February, before data showed us how relatively easy it is to significantly reduce the spread with changes to our behaviors. If we end up back on the growth trend in cases it will be because enough people are unwilling to wear a mask, wash hands, and avoid high risk activities. In this case, it may take herd immunity or a vaccine to stop COVID-19.

With over 110 vaccine candidates, things look promising for a vaccine (eventually), but it is likely 2022 before a vaccine is broadly distributed (e.g. 70% of people have gotten vaccinated or recovered with immunity). Some consumer behaviors will change upon a vaccine becoming available, which could be as early as mid next year. But we will still have a growth in infections and deaths until we get enough people vaccinated or recovered with immunity. On the topic of recovery with immunity, we now have enough data to report that the vast majority of those that recover from COVID-19 develop a level of immunity. We don't know how long the immunity will last or how virus mutation will or will not affect immunity. Time will tell.

The number of those with immunity is quite small, currently. Serologic studies show less than 5% have recovered from COVID-19 in most areas. Considering the rate at which herd immunity is accumulating, it would take us well into 2021 or 2022 before we achieve a 70% recovery rate. The cost of building to herd immunity would be deadly to hundreds of thousands and painful for millions of people.

It is hard to conceive of a way where this bad path doesn't undermine our economy for many years -- especially our economic competitors are able to stay on the good path and don't experience a second wave. If other economies are able to keep the infection rate R0 below 1.0, but the US doesn't, one should expect the US to become banned from travel, and isolated economically, with less willingness to depend on our supply chain, which could be disrupted by outbreaks.

How Can We Really Know What Path We Are On?

Early on in the pandemic, in February, I pointed out that the data was going to be a challenge for the US. Despite all our high tech abilities. I wrote about problems with our electronic death reporting systems (EDRS). Our EDRS is nowhere near where it needs to be, and that was just the tip of the iceberg in terms of challenges. As some states have opened earlier than others, there is concern that the data reported may not be reflective of the underlying infection rate. There is concern that politics might influence testing and reporting.

President Donald Trump, in a speech last week at a medical supply distributor described insatiable need for more testing. Though, puzzling, he said, “And don’t forget, we have more cases than anybody in the world. But why? Because we do more testing. When you test, you have a case. When you test, you find something is wrong with people. If we didn’t do any testing, we would have very few cases.”

I think we all understand that infections exists whether we test for it or not. Testing gives us vision so we aren't flying blind. But current testing is "active." It requires several affirmative steps to get tested and policy decisions of who gets tested and who doesn't. Even attempts at random samples aren't always random and representative. There is another way.

When I was a teen, I worked in a water/wastewater lab. Most of the work was cleaning test-tubes and beakers, but there were a few tests I got to perform. I gained appreciation for science of passive measurement. We know that the coronavirus is shed in the excrement of those infected. Every flush of the toilet is data. It is possible to measure the current level of virus in the community, and identify when it is decreasing versus increasing. Biobot is one of the companies leading the field. I've been tracking the story for the past two months, as well as encouraging its use in my community. When I reached out to Senator Heidi Gansert, I was happy to learn Biobot had been in touch and were working on implementing it in my area. I've not seen published data at scale as of yet, but I would encourage you to have your local government leaders participate. Passive testing of wastewater can give us an underling trend of COVID-19. It can warn us if infections are increasing.

The President acknowledged, in his speech, we want more testing. For the US, if all wastewater treatment plants applied the test daily, it would cover 75% of the US with measurement of the COVID infection rate. It is often more detailed than county level data because there are five times more wastewater treatment plants than there are counties in the US.

What wastewater measurement can't do is tell you who in the community has it. Pipes flow together and often there are thousands and thousands of homes served by each wastewater treatment plant. Septic systems are not connected, so that's a limitation as well. Nonetheless, it can provide a non-biased daily measurement of where infections are trending for 75% of US households. Such measurement would not be subject to who gets tested and who doesn't. While the source of measurement is pretty dirty, the measurement is pretty clean.

Conclusions:

Celebrate we are on a downtrend. Below is the chart through May 17th. It is good news. Help others recognize we are at a break point. We can keep COVID-19 on a downtrend if we adopt and stick with a few new behaviors, like wearing a mask.

Final suggestion: Contingency plan for your family and business: What if we stay on this good trend... What if the trend breaks bad? Are you ready for either path? Is every member of your family taking personal responsibly and contributing to staying on the good path? Are there others in the community that you can help in their time of need? Do they need a mask? I am headed out to drop a box of food off at a family that can use it. I'll include a couple of masks too.