By Hagop Kantarjian, M.D.
Nonresident Fellow in Health Policy, Baker Institute
and
Vivian Ho, Ph.D.
James A. Baker III Institute Chair in Health Economics
The impact of Covid-19 in Houston and Texas is still unclear. The Covid-19 peak was around mid-April, the doubling time of new cases has slowed from three days to 12 days, and the number of new daily cases is decreasing. This is reason for cautious optimism that Houston and Texas may have weathered the feared disaster of a Covid-19 peak (unlike New York, Spain and Italy). But we must continue with serious protective measures, and prepare for the future.
First, the bad news.
The Covid-19 pandemic is still in the early-to-mid phases in the U.S. and most of the world. It may continue to spread over at least the next several months, or even longer, infecting millions, killing hundreds of thousands, affecting international economies and industries, and altering social fabrics and dynamics.
As of April 24, 2020, Covid-19 has infected 2.8+ million people worldwide (still only 0.035% of 8 billion) and caused the death of 195,000+. In the U.S., 900,000+ Americans have been infected, and 51,000+ have died (mortality rate 5.7%). This mortality rate is higher than the 1% mortality rate in selected geographies with widespread testing, suggesting that the exposure rate to Covid-19 (with or without symptoms) may be 5-10 times higher than reported so far. The true “exposure,” “clinical infection” and mortality rates will be clarified once widespread nasal and serology testing for Covid-19 are widely available.
With very limited testing, mostly of people with symptoms, it appears that less than 1% of the world population have been infected. This may be higher in epicenters like New York, and among health care workers (HCWs). Even if we assume the exposure rate to be 10 times higher, a 10% exposure rate is far below the 60% level needed to develop herd immunity. The pandemic will continue until one or several of the following conditions happen: 1) safe and effective vaccines or, short of this, drugs that suppress the virus (like with AIDS) are discovered; 2) herd immunity develops, either through exposure to Covid-19 or through vaccination, in 60% of particular populations; or 3) with some luck, the virus develops mutations that attenuate its effects (this happens with other viruses) or is susceptible to warm and humid weather (this will buy time during the summer season). Until then, measures to flatten the curve will reduce the viral spread to a simmering “slow-motion” pandemic that waxes and wanes, and that may reactivate when social precautions are lifted.
The U.S. delayed implementing preventive measures by four to six weeks, and widespread Covid-19 testing is still vastly insufficient even today. Short of vaccines or treatments, the best Covid-19 control measures that will produce the lowest infection and death rates depend on: 1) prevention with hygiene, personal protective equipment, and social distancing and lock-downs; and 2) early and widespread testing, contact tracing and quarantines. We now know that 80% of Covid-19 spread may be caused by the 25% to 50% of infected people who have minimal or no symptoms. Without optimal testing, contact tracing and isolation, Covid-19 spread will continue. In such epidemics, one week of delay in implementing preventive measures may increase the epidemic size three-fold and delay its control by one month. A recent analysis estimated that 90% of the deaths in the U.S. could have been averted if social distancing had started two weeks earlier. There has been much discussion of optimal Covid-19 testing with nasal swabs and serology, and its impact on ending geographic lock-downs, and reopening industries and work environments, while also protecting highly vulnerable people (for instance in nursing homes, or in medical facilities), and protecting the Texas Medical Center (TMC). The TMC cares for more than 10 million patients every year in 26 hospitals, and employs 106,000+ HCWs. These dense facilities with frequent patient-patient and HCWs-patient interactions can be prime potential areas of Covid-19 spread.
Some experts, including the director of the Centers for Disease Control, have expressed concern that a second wave of Covid-19 will be more deadly because it will likely overlap with the seasonal influenza. However, the lessons learned from Covid-19 (hygiene, social distancing, PPEs) will continue, and the heightened awareness will lead to more people getting the influenza vaccines. This may in fact reduce the overall risks and mortalities from both Covid-19 and influenza. Moreover, a second wave of Covid-10 may not happen, or it may happen with a mutated, attenuated virus, or after anti-Covid-19 vaccines and drugs become available. So the “bad news” may actually become “good news.”
Then, the good news.
In previous articles for Rice University’s Baker Institute for Public Policy, we — unlike most experts — projected cautious optimism about the outcome of the pandemic, provided effective anti-Covid-19 measures were implemented. We did this based on 1) the particular conditions in Houston and Texas (unlike New York — less dense population, widespread geography, less tourism influx, warm humid weather, little mass transit), 2) the early closure of the Houston Livestock and Rodeo Show (March 13, 2020), 3) the implementation of a city lockdown on March 16, 2020, and 4) a needed quarantine period of four to six weeks. Incorporating that information, we estimated the Covid-19 surge/peak to occur between April 10 and 17, and the virus to recede by May. These two “back of a cocktail napkin” predictions turned out to be more reliable than the sophisticated modeling systems. And the infection and mortality rates in Houston and Texas remain relatively low. This is with the caveat that Texas has a very low testing rate for Covid-19. So it appears that our city and state may have passed the worst, provided we continue with the prevention measures, watch for the daily number of new cases to decrease to low double or single digits over several days, and implement as soon as is feasible wide nasal and serology testing in 100% of instances where needed, particularly in the TMC. This will facilitate a safer opening of our city and state, and a reinvigoration of our economy. In addition, we hope that the experience with the Covid-19 pandemic will serve as a catalyst to readdress health care inequities that are being highlighted during this period and will convince more Americans of the importance of universal health care as a human right and a humane necessity.
While many experts indicate that it will take a long time to develop anti-Covid-19 vaccines and drugs, we believe otherwise. Only four to five months into the Covid-19 pandemic, millions of researchers, many large health care companies and numerous public health infrastructures worldwide are investing huge amounts of time and resources, and multi-billions of dollars, to investigate hundreds of potential vaccines and treatments. Already, five of a potential 80+ vaccines are in clinical trials, and more than 100 drugs are being evaluated in laboratory settings and clinical trials. With our human ingenuity and knowledge, and these formidable collaborations, we should find good vaccines and drugs in the near future.
And there may be positive legacies of Covid-19, some of which seem to be starting to materialize. The awareness of continued preventive measures and benefits of vaccines may reduce the annual mortality rates from influenza. What might have taken years to implement has recently taken just weeks: strategies to transition to remote working, less reliance on physical mass gatherings and meetings, and virtual medicine. There is already a noted trend of reduced mortality from car accidents and lower crime rates. We are also realizing that even as little as one to two months of Covid-19 containment measures are already having favorable effects on the rate of global warming, and that such measures may require adaptation but are possible in order to save our planet from dire consequences.
Now, a look into the future.
Our new normal life in the time of Covid-19 will be different. In high-risk periods (as we are now), testing for Covid-19 should be routine (like measuring temperature or blood pressure) and widespread: PCR nasal swab testing for anybody with symptoms; a serology one-time test offered to all, then periodically (monthly), to identify people who have immunity. Within TMC, there is an added responsibility to prevent the spread of Covid-19 among the most vulnerable patients, HCWs and their contacts. During high-risk Covid-19 periods, all of them should be tested routinely and frequently.
In addition, the new normal should include better hygiene and social distancing; more virtual communications; enhanced capabilities to work from home; universal health care; and better-prepared health care infrastructures. Finally, to avoid the stumbling blocks encountered during this pandemic and to be better prepared for future events, we must eliminate much of the bureaucracy accumulated over many years across multiple disciplines, as it does not improve quality or safety, and increases cost and delays.
Authors
Hagop Kantarjian, M.D., is a medical oncologist and a nonresident fellow in health policy at the Baker Institute. His opinions do not reflect those of his institution affiliation.
Vivian Ho, Ph.D., is the James A. Baker III Institute Chair in Health Economics at the Baker Institute, a professor in the Department of Economics at Rice University, and a professor in the Department of Medicine at Baylor College of Medicine.