The Anticlimactic Ending to the Covid-19 Pandemic
Covid-19 in the US is a raging forest fire. What will rise from the ashes?
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Having observed undoubtedly one of the most unusual Independence Day celebrations in our nation’s now 244-year history, we find ourselves in the midst of an increasingly worrisome stretch of the coronavirus pandemic.
At a time when cases are rising, authorities are enacting more stringent mitigation measures, bars and beaches are closing, and critical care units in some states are approaching capacity, it’s easy to understand why the stress and uncertainty that started to subside in April and May are back on an upward trajectory. What now? Where is the pandemic heading? What can we expect going forward?
A quick glance at the title of this story might prompt you to wonder if I’m going to explain away some silver lining in all of this, that we’re just experiencing the proverbial dark before the dawn. Well, not exactly. Instead, we’re on a steady burn. While its lethality may have peaked, the virus, SARS-CoV-2, certainly isn’t done ravaging our country. Don’t take my word for it though, let’s look a some of the latest data to project what the future holds.
On the left is a trendline for the number of Covid-19 cases in the US over the past 3.5 months, and on the right is a look at the number of deaths over that same time period.
While the number of cases and deaths are trending differently in some states compared to others, the overall trend for cases across the country is on an uptick while deaths remain on a decline. Changes in the number of deaths lag behind changes in the number of cases. Therefore, because of the recent climb in cases, we can expect the declining death rate to level out or possibly increase to some degree in about 2–4 weeks.
The main take away from the graphs above, however, is that despite an almost constant caseload of 20–35 thousand per day from mid-April to mid-June, the number of daily deaths over a two-month timeframe (accounting for the 2–4 week lag) declined by around 80%. Let’s talk about why this happened and why it’s important.
Cases are occurring in younger individuals. In March, the average age of a patient with Covid-19 in Florida was about 65 years. By mid-June, it dropped to 35 years. Below are age-based trendlines for cases in South Carolina. Notice a pattern? Look how much the lines representing individuals aged 11–50 have shot up.
Since we know that the risk of death from Covid-19 declines sharply with age, it should come as no surprise that a shifting case demographic towards younger people will result in a decline in the rate of deaths.
Another reason for the decrease in deaths is that care is improving. Remdesivir showed a trend towards reduction in mortality that fell just short of statistical significance. Pre-published data on anticoagulation demonstrates a number needed to treat (NNT) of 3 to prevent one death from Covid-19 in mechanically ventilated patients. Likewise, another preprint trial indicates dexamethasone may reduce mortality with a NNT of 25 in patients receiving supplemental oxygen. Even non-pharmacologic interventions, like pronation, are likely beneficial.
One additional factor that could at least partially explain the decline in death rate is that a greater number of mild infections are being diagnosed. This would likely be due to increased screening of asymptomatic individuals and, to some degree, because of an increase in the availability of tests.
So, we’ve identified reasons for the drop in death rate in the face of stable cases. Now, we need to understand why this occurrence is important.
In April, the Center for Infectious Disease Research and Policy (CIDRAP) released the first of its Viewpoint publications outlining three likely scenarios for how the Covid-19 pandemic will unfold. These scenarios were developed based on data from prior influenza pandemics as well as knowledge of how coronaviruses generally behave.
At the time, one possible scenario considered was that of a sharp decline followed by a trough in cases over the summer and a large second wave in the fall. Based on the data discussed earlier, this scenario (#2) now looks unlikely. We appear to be headed for something closer to scenario 3, or perhaps a mix of scenario 1 and 3.
The director of CIDRAP, Dr. Michael Osterholm, agrees and stated on the June 21st episode of Meet The Press,
“I’m not sure that the influenza analogy applies anymore. I think that wherever there is wood to burn, this fire is going to burn…I don’t see this slowing down through the summer or end of the fall. I don’t think we’re going to see one, two and three waves. I think we’re going to just see one very difficult forest fire of cases.”
The steady burn to which Dr. Osterholm refers is the path the novel coronavirus is taking towards becoming endemic. Just like four of its coronavirus siblings, SARS-CoV-2 is destined to circulate throughout the population slowly weakening and becoming more like the common cold as our collective immune systems learn how to recognize and defeat the virus. For a more detailed depiction of this concept, take a look here:
Like many of us, you may be waiting for the announcement of a successful vaccine as a signal that we can all finally celebrate the end to one of the greatest world-wide disasters civilization has ever endured. That sounds like a pretty happy and climactic ending. So, why the prediction of an anticlimax?
Don’t get me wrong, I still think there will be a happy ending for society. I also think a safe vaccine is likely to be produced and could potentially play a role in helping bring the pandemic to an end. But I suspect we crave a vaccine more now than we may whenever it becomes available, perhaps in early 2021. While I’m thankful for those who are pursuing it, my guess, and it’s just a guess, is that the vaccine will become an afterthought. Herd immunity is coming whether it arrives with help from a vaccine or not, and there are now reasons to believe herd immunity is closer than previously thought.
A recent study published on June 23rd in Science estimated the threshold for herd immunity to be 43%. That means it’s likely that only 43% of the population would need to become immune to the novel coronavirus in order for its transmission to slow and eventually stop. This is significantly lower than prior estimates of 60–70%. In addition, on June 25th representatives of the CDC estimated that 5–8% of the US population had already been infected with SARS-CoV-2, and this was based on data from March through early May. Add in the recent revelation that 40–60% of individuals who have not been exposed to the novel coronavirus carry T-cells that are reactive to SARS-CoV-2 likely as a result of immunity developed to one of the other endemic coronaviruses. All this new information favors an early arrival of herd immunity.
“This is the way the world ends
Not with a bang but a whimper.”
- T. S. Eliot, The Hollow Men, 1925
No, I don’t think the world is ending, but just like the world described in Eliot’s poem, the pandemic is more likely to taper than halt. Remember the forest fire? By the time 2021 rolls around that steady burn will have faded to a smolder. This is the anticlimax we can expect. There will be a happy ending for civilization, but we won’t notice its arrival any more suddenly than we notice the grass growing or the advent of springtime. It will just sort of happen, and we’ll all be glad it did.
So, what now? Does this understanding of how things likely play out actually affect anything we do? Consider this. Could the forest fire analogy also apply to our nation’s interest in the coronavirus? By 2021, will our concern have dwindled to an ashy glow? I’m not talking about the worry and the fear. I think most of us are wanting those to go away as soon as possible. I’m talking about the concern and care for one another.
We aren’t powerless. Much to the contrary, even our simplest actions can produce a dramatic effect when multiplied by many others doing the same thing. We still have the opportunity to reduce the spread of the virus and protect those at greatest risk of complications. That includes taking appropriate and reasonable precautions like wearing a mask especially when there is potential for an encounter with a vulnerable person where physical distance cannot be maintained.
But this power won’t be realized if we suffer from alarm fatigue. This is the anticlimax we can prevent. We must remain vigilant because the pandemic is far from over. Many more cases, and sadly, deaths lie ahead. Let’s not make that number any higher than it otherwise would be. Besides, it’s not just a number. It’s a grandfather, it’s a child with cancer, it’s those with heart disease, it’s minorities, it’s our neighbors, our family, and our friends.
“An individual has not started living until he can rise above the narrow confines of his individualistic concerns to the broader concerns of all humanity.” — Martin Luther King, Jr.
Yes, we will overcome this virus. What happens between now and the anticlimactic ending is up to us.
Thank you for reading. This story has garnered support from multiple physicians and medical providers. For more information on the coronavirus pandemic, please take a look at Medium’s Coronavirus Blog found here.
