Social distancing and lockdowns: Will it work?

Yes. But with a price to pay.

Life in the metro, and in most parts of the world, has drastically changed in the past few days. As more new cases of the novel coronavirus are being reported, some people seem to be losing it. Literally, jumping the gun and going gaga over the additional cases that are being reported.

Epidemiologist, Adam Kucharski in his book “The Rules of Contagion: Why Things Spread and Why They Stop” proposes an interesting perspective on this topic during this lockdown period.

Flattening the curve: What does it mean?

Li, Pei, et al. in Science (16 March 2020) published an article analyzing the prevalence and contagiousness of UNDOCUMENTED novel coronavirus (SARS-CoV2) infections is “critical for understanding the overall prevalence and pandemic potential of this disease.” That publication (which serves as an interesting read) estimated that 86% of all infections were undocumented before travel restrictions were imposed in China on January 23, 2020. “Per person, the transmission rate of undocumented infections was 55% of documented infection, yet due to their greater numbers, undocumented infections were the infection source for 79% of documented cases. These findings explain the rapid geographic spreads of SARS-CoV2 and indicate containment of this virus will be particularly challenging.”

The study indicated that multiple factors including: identical and isolation of undocumented infections, awareness among health care providers, availability of viral identification assays, use of face masks, restricted travel, delayed school reopening and isolation of suspected persons can potentially slow the spread of the disease. Combination measures increase the reporting rates, reduce the proportion of undocumented infections and decrease the growth and spread of infection.

The lessons learned from the outbreak of the novel Coronavirus in Wuhan is a bitter pill to swallow for the global community. Experts in epidemiology talk about “flattening the curve” in order to primarily slow down the acceleration of number of cases. By slowing down the case rates, the burden and demands on various resources of the healthcare system is indirectly addressed.

Without intervention during a pandemic outbreak, the number of cases continue to rise, significantly overwhelming the healthcare system. Temporary intervention measures include lockdowns, quarantines, isolation and social distancing. It reduces the peak number of cases thereby reducing the number of overall cases. A disease declared as a pandemic will take years to eradicate. The discovery of vaccines may provide the long-term solution but it is not something that will occur overnight.

A pandemic will take time to naturally “flatten” on its own. Because of the initial overwhelming burden on scarce resources of healthcare (especially in third world countries), the death toll will be much higher. Those at the forefront are primarily affected. If there are less healthcare workers to tend to more sick people, the mortality and morbidity rate increases. If there are more sick people that will need hospital beds and ventilators because of more severe COVID-19 infection, the already limited resources are usurped more quickly. Scales of outcomes then become dependent on financial capacity for better and more aggressive care.

In epidemiology, the idea of slowing a virus’ spread so that fewer people need to seek treatment at any given time is known as “flattening the curve”. It explains why so many countries are implementing “social distancing” guidelines.

Brandon Specktor, Coronavirus: What is ‘flattening the curve,’ and will it work?, LiveScience, March 17, 2020
The broken lines represent the health care capacity of a country.

In the above graph, as the number of people disproportionately increase and no precautions are placed, the health care capacity is exceeded, exhausted and fails. In order to maximize (not overwhelm) the health care capacity, there is a need to slow down the infection rate. Flattening the curve assumes that the same number of people ultimately get infected, but over a longer period of time.

Does it work?

In 1918, a global pandemic of Spanish flu was seen. Compare two U.S. cities – Philadelphia and St. Louis. Infectious disease experts warned of the flu spreading in communities. The reaction of both communities was different. A massive parade went as scheduled in Philadelphia, gathering hundreds of thousands of people together. In 2-3 days, thousands of people in the Philadelphia region started to die. At the end of six month, 16,000 deaths were recorded. In St. Louis on the other hand, the city officials implemented social isolation methods – schools were closed, travel was limited, personal hygiene and social distancing was encouraged. At the end of six months, 2,000 deaths were recorded – 1/8 the number in Philadelphia.

How long is this going to last?

That’s the question that’s begging for an answer.

Unlike 1918, we’re living in a different era. More than a century later, our tools at combatting infectious diseases are more rapid, accurate, and precise. But even cutting edge technology and digital advancement won’t solve this problem overnight. One avenue science has not caught up with is a contagion unknown by all. When the enemy is new, the learning curve is steep. Which means that it will take in casualties before we know how to deal with it.

This will not go away anytime soon. With appropriate mitigation measures – both medium- and long-term – we will be able to suppress this. We need to bring the number of reported cases down using ancient aggressive epidemiological tools – social distancing, quarantine, lockdown of high risk communities, and testing patients. Belligerent testing, case finding, contract tracing are vital to keep the cases declining. When the dust finally settles, the government should put into place an overlapping long-term plan on how to keep the numbers down. For example: (1) all people who travel should have mandatory quarantine of a minimum of 14 days upon arrival. (2) Everyone who comes in contact with a COVID-19 positive patient, should undergo testing, monitoring and self-quarantine regardless of test status (if any). (3) Social distancing should be norm for the next few month until this blows off. (4) Schools may need to get cancelled for the rest of the school year. (5) Vaccine-preventable diseases should be mandatory for all so that we are not taken aback when another outbreak (preventable at that) surprises us in the future. (6) Honesty is a direly lacking trait among Filipinos. For more personal reasons for that matter. (7) Sale and events that will entice a crowded group should be canceled up to the year end. But these are just examples and I am sure people will get upset to some degree.

Eradication is another story altogether.

Someone asked me if this will ever go away. The answer is no. I don’t think so. One strategy to making this vanish is to develop a vaccine at best. But like any new drug, this isn’t like some Avenger movie where a vaccine is developed in a couple of hours, needle plunged into the arm, and presto – we’re immune! This will take quite awhile because whatever is developed out there needs to get tested for safety and efficacy. How long will it protect you? Do you need added doses? What’s the immune response to the vaccine? What are the short and long-term side effects? We all want to be guinea pigs during a crisis.

Let me end this by saying that it’s okay to be disappointed with what’s happening. Sadly, we still have a lot to learn about this virus. And how it will play out. The worst will spare many of us. But only resilience will make us survive this pandemic. Yup. The pandemic will end. As it did with the Spanish Flu of 1918, it ended in 1920. With the novel coronavirus, “what we don’t yet know is when.”

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