George Delgado, MD
As we see more COVID-19 cases in the United States, there is much debate about the best strategies to employ to get through the pandemic. Many Americans have relaxed their adherence to mitigation measures (“COVID-19 mitigation fatigue”); some states have rolled back restrictions while others have increased them. We need to move to a more reasoned, rational approach to mitigation that is proportionate and makes sense. We should emphasize protecting those older than age 65 and those with serious medical conditions. Health departments should focus their educational efforts on these groups so that everyone fully understands the risks. Those with little risk should be allowed to restart businesses and return to work or school. Infections will rise and then fall but if those in high-risk categories are protecting themselves, death rates will continue to decline.
A recent highly publicized case in California illustrated the danger of mitigation fatigue. Two critical mistakes led to the death of a 51-year-old man with diabetes and obesity. Apparently, the man had been very careful throughout the pandemic, avoiding unnecessary gatherings. After many weeks of self-quarantine, he decided to attend a barbecue with family and friends. Attending the same party was a man who knew he had tested positive for the novel coronavirus but attended anyway because he did not have symptoms. [Press Enterprise Article] The 51-year-old man would likely still be alive if he had worn a mask and practiced social distancing (or not attended the gathering) or if the infected man had skipped the party.
Mitigation measures have been perceived as heavy-handed and as a one-size-fits-all strategy. Beaches and public parks have been closed (and opened then closed again) even though there are no data to suggest that spread of the virus might be a problem outdoors, where fresh air, breezes and the room to space would undoubtedly decrease, not increase the chance of infection. The only reason I can find that public officials are so concerned about beaches is that they are afraid that, with the sun and surf, caution is tossed to the wind. Instead of educating and managing, many states have only wanted to restrict beach access by closing the beaches themselves or passively by padlocking parking lots. CDC has issued commonsense considerations for beaches. [Considerations for Public Beaches]
Schools have been closed even though the data show that children are the least likely to contract COVID-19. Additionally, there is no good evidence that asymptomatic children are spreading the virus [Pediatrics: COVID-19 Transmission and Children]. Studies in Iceland indicate that children are very unlikely to spread COVID-19 to adults [New England Journal of Medicine Iceland Study]. In fact, the CEO of deCode, the company involved in the Icelandic study, was quoted as saying that there have been no discovered cases of transmission from a young child to an adult in Iceland [deCode CEO Interview]. Sweden, Nicaragua and Taiwan never closed schools while Germany, Iceland, Israel, Canada, Norway and other countries have reopened them. [Edutopia Article: Schools are Opening Worldwide], [Science Magazine Article: School Openings Across Globe], [The Globe and Mail: What Canadian Educators Can Learn from Sweden]
Another question that is frequently overlooked regards the goals of mitigation measures. Are the goalposts being moved, as some have suggested? We all readily undertook some of the most drastic measures of our lifetime because we feared that hospitals would be overwhelmed, personal protective equipment (PPE) shortages would develop and millions of people would die. Our hospitals are not overrun, PPE is available and deaths are at less than 150,000 (as of 11 July 2020). Clearly, we have achieved our objectives with the mitigation measures.
Second Wave Infection Demographics
The recent surge in cases, confirmed by an increased percentage of tests that are positive and increased hospitalizations, have not been accompanied by an increased number of daily deaths, nationally. That is because the increased cases are predominantly younger people who generally fare better than older folks. Additionally, we physicians are improving our bedside therapies for COVID-19, almost daily.
The recent increases should have been expected. The combination of mitigation fatigue, a relaxation of restrictions and thousands of protesters congregating without social distancing and with plenty of yelling, in May and June, obviously led to more cases in the under-60 crowd. The data show that the average age of new cases has shifted downward.
A credibility gap has developed. The more arbitrary, retaliatory and punitive government decrees, restrictions and regulations appear to those under the age of 60, the less likely they will be followed.
Closing the Public Health Management Credibility Gap
What’s a smarter way to manage COVID-19 mitigation strategies? The first is to focus on educating our people about the true risks involved with different activities and then treating them like adults who usually make prudent decisions. The second is to be precise with data-driven, specific restrictions that focus on protecting our most vulnerable, the elderly and those with chronic diseases, while keeping a close eye on ICU capacity.
There should be a gradation of restrictions and recommendations, strictest for nursing home patients and lightest for those under the age of 20. Schools should be opened with measures in place to protect those who might be endangered there—teachers who have chronic medical problems or are over the age of 65. A classroom with a healthy 30-year-old teacher can look a lot different than a classroom with a 70-year-old teacher.
COVID-19 Risk Scores
We can look to research in the future to risk stratify the vulnerable. While a scoring system may seem arbitrary, it could help vulnerable people assess their risks and act accordingly. The 51-year old who died in California may have acted differently if he knew he had a high “COVID-19 risk score.”
According to CDC, there are seven conditions that have definitely been linked to poor outcomes with COVID-19. They are obesity, diabetes, serious heart disease, kidney disease, sickle cell disease, COPD (emphysema) and immunodeficiency related to organ transplant.
Age is a definite risk factor. Of those that have died, 80% were 65 or older, according to CDC. Ioannidis did an analysis of US and International data and found that in New York City those under age 65 with no underlying conditions only represented 0.6% of the COVID-19 deaths. [Ionnidis Article:Population-level COVID-19 mortality risk for non-elderly individuals overall and for non-elderly individuals without underlying diseases in pandemic epicenters]
A Common Sense Go Forward Strategy
Policymakers should tolerate spread of the virus—as long as the hospital system is not overwhelmed, we have enough PPE and daily death rates are not increasing. We need fixed and clear goals. Increased infections, as long as they do not involve the elderly or medically vulnerable, are an unavoidable path to herd immunity. Our “flattening of the curve” has once again proven the axiom: “You can pay me now or pay me later.” Holding out for a vaccine is impractical and likely naive, in light of previous vaccine failures with other coronaviruses.
Various SIR (susceptible, infected, recovered or resistant) models, such as our own Monte Carlo Covid Decision Model, are able to calculate R(t), the reproduction number of the virus over time. An R(t) of one means that one person with the virus will infect one person who will infect one person, etc. The number of infected people will be stable. An R(t) less than one means the pandemic is losing steam. An R(t) greater than one indicates a growing pandemic. At the start of the pandemic, the R0 was 2.5 to 3.5. Now, in various parts of the country the R(t) is ranging from 0.8 to 1.36, according to Rt COVID-19 [http://rt.live].
Monitoring the R(t) is like having your finger on the pulse of the patient. If R(t) climbs above 1.1 or 1.2, targeted mitigation measures can be increased. If it dips below 0.9 the measures can be loosened. Increasing or decreasing restrictions should not be seen as a sign of poor foresight but as a dynamic titration process that seeks to maximize individual freedom while protecting the vulnerable.
Other important indices to monitor include daily deaths (which lag behind new infections by about two to three weeks), percentage of tests positive (a much better indicator than simply positive tests) and daily hospitalizations. Watching ICU and ventilator capacity is very important, too.
Conclusion: Data Driven Policies with Risk Modulated Behavior
The rational approach to the COVID-19 pandemic is to prudently use the best indicators while focusing on protecting those older than age 65 and those with one of the seven serious medical conditions. Health departments should focus their educational efforts on these groups so that no one else makes the fatal mistakes that the two party-goers did in California. The rest of the population should be allowed to carefully venture out into the world (with appropriate social distancing and other precautions), recognizing that for the next few months we will see a steady rate of infections, most which will be mild.
6 thoughts on “Rational Policy Strategies for the COVID-19 Pandemic”
- Marijo Zafra
A much more sensible and practical COVID19 policy review. Thank you Dr. Delgado.
- Patricia Tooker
I appreciate your comments, Dr. Delgado, but are you suggesting that people age 65 and over should have mandatory restrictions placed on them? Meanwhile, younger people can be treated like adults, given the facts, and allowed to make their own decisions as to what they choose to do. As a person over the age of 65, I have become increasingly concerned that I will be forbidden to travel by car from state to state, to check into a hotel, to board a plane, to eat in a restaurant, to go to a dentist, to get my hair cut, to shop for groceries, or enter a big box store. I am also very concerned that working people will be forced to resign when they hit that magical age of 65, or maybe 60, or maybe 50, as they are now considered “vulnerable,” and a threat to themselves and the health care system. Will plumbers, electricians, appliance repair people be required by law to don extensive PPE to enter the home of anyone over a certain age, if they even agree to come? Will those of us over 65 no longer be allowed to attend Mass, lest we somehow catch a cold? Life is full of risks. Not everyone wants to skydive, but most people are willing to get into a car, even knowing that most accidents occur within a mile of their home.
- Bill Goyette
A healthy senior should not be restricted by law, but informed of their actual risk and act accordingly. A crowded bar or indoor event would be highly risky and something to be avoided. In practical terms, work places are likely to be very accommodating to those at risk, allowing continued remote learning or work arrangements that reduce risk and protect vulnerable employees. We see this in place in the businesses that have reopened. They are protecting employees and the public. Service businesses likewise are taking precautions for their employees and clients. For these items and well run restaurants, the risks are minimal and people are protecting both workers and customers. Likewise for schools, we would advocate reasonable protection for vulnerable teachers or students (rare, but they do exist).
An informed person with some relative risk should be selective in their choice of business … and the good ones are advertising with this message: we are protecting you and our staff. Whether this requires guidelines, regulations, certifications or licensing is a practical discussion, but in the short term, the market is driving this, as people are very concerned and businesses recognize this.
Churches are being cautious now and are encouraging older people to stay home. We would recommend a shift that puts in place means for more at risk people to attend (maybe a mass or service at a specific time with extra protections). Generally the practices we see in place in CA are abundantly safe even among older people, some of whom are attending, and choosing to take a very low risk. We would recommend that the highest risk individuals should continue to minimize their public exposure.
Those in long term care facilities are not in control of their mobility and need to be protected, as their connectivity within the institution is high, and the disease can spread rapidly between patients and staff. Special restrictions and disciplines need to be in place, and in general, this is true.
Overall, we do NOT advocate limiting individual behavior by law, but we do advocate informed decisions. We advocate broad implementation of reasonable safety protocols to protect employees and customers. If an older individual living independently becomes infected the risk of secondary spread to others is very low because of low connectivity, so they should not be restricted on those grounds. Their needs to be a reasonable balance between the risk of COVID-19 and all the other risks we routinely accept as part of life.
- J. Abraham
In both cited papers (the Iceland study and the COVID19 Transmission and Children), the sample size used as a basis for the study are too small to be used to accurately formulate a conclusion. As a result, the basis for conclusion in this article is flawed.
- Bill Goyette
We do know that infection rates are very low for children and mortality rates are exceedingly low for COVID-19 as compared to the flu: https://data.cdc.gov/NCHS/Provisional-COVID-19-Death-Counts-by-Sex-Age-and-S/9bhg-hcku
Hospitalization rates for children are also exceedingly low: https://gis.cdc.gov/grasp/COVIDNet/COVID19_5.html
So the evidence is clear that children are not particularly vulnerable and the flu poses a much greater threat.
As to the question of transmission from children to adults or others, this still merits further study, but the evidence presented here on a fairly large sample set indicates that in less than 10% of households did the child test positive before any adults.
So kids get it at much lower rates and transmit the disease at much lower rates;this multiplies out to a very low risk level.
We agree that a teacher who is at risk should be provisioned for to minimize their exposure and risk. When one ways the practical balance of all the effects of shutting down schools, including teen suicide and social disruption, the relative risk of kids returning to school seems quite low and manageable.
If the disease was simply propagating among children, their inherent resistance a low transmission rates would be far less the a reproduction factor of 1. This would be a study to look for.
- Norbert Kovács
Dear Dr. Delgado,
thank you for your excelent article. As a medical practitioner from Spain, I share most of your thoughts and views.
However, I am concerned that the fact that not only daily deaths but also any increase in hospital admissions, ICU bed occupancy or decrease in available PPEs lag behind new infections.
During that time, if an uncontrolled infection rate is not observed/suspected, due to the very nature of pandemics, the increase of infections (and the paralell decrease in resources) will be exponential. This was very rightly pointed out in an other article of this website.
My personal experience tells me that (too) many local policy makers (hospital managers in charge, as a sad example to quote) remain fully unaware this fact and fail to react timely or even worse as many politians do, they overreact in a fear to fail in the eyes of public…again.
Finally, I would welcome to read many more articles on your website. If it is at all possible, some of them should present comparative data on predicted outcomes with mitigation measurements in the USA and the final outcomes.
Norbert Kovács, MD