ASK AN EXPERT: COVID-19 DOS, DON'TS AND WHAT TO EXPECT

With the COVID-19 global pandemic affecting all of our lives, we spoke with a long time friend of Stan’s NoTubes, Dr. Matt Ferrari, Associate Professor of Biology at the Center for Infectious Disease Dynamics at the Pennsylvania State University. When he’s not studying infectious disease, Dr. Ferrari is on one of his bikes, riding the trails and roads around State College, Pennsylvania. We wanted to find out how a serious cyclist, active member of our riding community, and specialist in epidemiology, is reacting to this threat.

Stan’s NoTubes: What do you do professionally, and how is it relevant to the COVID-19 pandemic?

Matt Ferrari: I’m a quantitative epidemiologist which means that, broadly speaking, I study the number and distribution of people that are affected by disease. Normally, I spend most of my timing studying childhood infections like measles and rubella in low and middle income countries.

Stan’s NoTubes: Can you give us some insight into the importance of counting cases and studying the distribution? We know it's important, but how is that data used?

There are three reasons why it’s important to count cases of infectious disease. They are really relevant right now with COVID-19:

1. To know how much disease there is. Just getting a sense of how many people are infected and sick is non-trivial. It’s not easy to figure that out when it’s spreading quickly.
2. To evaluate whether our interventions are working. We do that by tracking numbers over time. We want to know if trends are being consistent with the interventions being put in place.
3. To predict into the future. We use models to scope out different possible futures and make decisions about what we should do now to get the outcomes that we want.

SNT: Let’s start with the basics of this pandemic. How is COVID-19 like other viruses such as the common cold or the flu and how is it different?

MF: In most ways, COVID-19 is exactly the same. If you want to get technical, it’s an RNA virus transmitted by respiratory droplets. The best ways to combat it are by practicing good hygiene and avoiding ill people. It tends not to be very robust outside of the human body, but it can stick around on surfaces for a little while. If someone coughs or spits on something and you touch it with your hand and put it in your mouth, that’s one way the virus gets transmitted. In controlled studies, you can get COVID-19 to last on hospital surfaces like stainless steel for a long time, but on the day-to-day surfaces that most people interact with, it doesn’t last long. If you wash your hands, you break the cycle of transmission, even if you have touched a surface with the virus on it. What’s different is that COVID-19 spreads quickly--faster than influenza, and the age distribution at risk and the way it causes disease are different. It affects people who are older and people who have metabolic or circulatory or cardiovascular disease more, whereas the flu is worse in both older people and young kids. COVID-19 is different in that it doesn’t generate a lot of severe disease in young kids, but it does generate some, so you still have to be careful. You don’t want your kids getting sick or spreading it to others.

SNT: Why is COVID-19 causing this level of disruption?

MF: There are a couple of reasons for this--all of which arise from the fact that this is brand new. A brand new virus means that every human being on the planet is immunologically naive to this. That can’t be said for any other circulating virus. Even influenza, which is usually a new strain every year, is not 100% new. Everyone who has previously been infected with a similar flu strain will have at least some partial immunity. So, influenza spreads slowly around the globe, in a really predictable manner. There is a regular season, we plan for it, we have a supply chain in place, hospital administrators plan staffing levels in advance of the flu season. We know flu season is coming, we pre-order supplies in anticipation. Flu is like lighting a camp-fire--it might take a few tries and it will burn slowly.

This thing is like taking a match to a 3-month old Christmas tree.

So there is a massive increase in upper respiratory illness, with a high fraction that are complicated, at a time of year when we weren’t prepared for it. That’s why we’re running out of supplies, which doesn’t happen in flu season. One can say, "It's just the flu, we'll all get sick, and it will be fine," but for 20% of patients it isn’t “just flu”; they need to be hospitalized or in an ICU, and we just don’t have that surge capacity. Italy has more hospital beds and ICUs per capita than us (3.2 vs 2.8 per 1,000).

The other big issue with this thing being new is that we don’t have a well developed standard of care. Health workers are learning how to treat this on the job. The clinical decision points don’t present the same as flu. Our docs and nurses are learning--but they're doing so in battle ground settings unless we slow the rate of patients coming in. So that’s why the physical distancing--because it’s all we’ve got right now. Distancing and testing are our only real tools. As we get more testing on line, we’ll be able to loosen the distancing restrictions. We can test, treat, and isolate the infected, rather than isolating the healthy now because we can’t tell the difference. That will buy us time to get off label approval for existing drugs.

SNT: You said earlier that it’s important to know how much disease there is. Why is that so difficult with COVID-19?

MF: What makes it so hard to track is that a large portion of the population will get a mild, asymptomatic infection. People don’t know that they are sick and thus don’t know that they should isolate themselves. That’s why “physical distancing” is so important as a tool.

SNT: Is “physical distancing” the same thing as “social distancing”?

MF: Yes, but it changes the meaning a bit. We want to separate ourselves physically to reduce the risk, but we're not trying to isolate ourselves socially.

Physical distancing is an activity that we do as a community for the benefit of everyone. Something that we’ve seen in crises like this--in other outbreak settings--is a lot of psychological stress. It’s due to the fear and stress of the possibility of getting sick and what that will mean as well as the isolation that comes with the distancing. We miss human interaction. There is also a lot of uncertainty about how long it will last.

We want to prevent the secondary psychological epidemic that could happen on top of the physical epidemic. Maintaining social contact through phone calls and video calls is important so that people don’t feel isolated.

SNT: How does physical distancing combat the spread of the virus and what about COVID-19 makes physically distancing important?

MF: Unfortunately, when we don’t know who is sick, we all have to act like we all are sick to prevent ourselves from infecting others. With COVID-19, it takes five to six days from contact with the virus until people experience symptoms. Any one of us might be in the five-to six-day period and not know it. Plus many infected people will experience no symptoms at all.

SNT: What practical advice do you have for us all to deal with COVID-19? What should we do, and what shouldn’t we do?

MF: Wash your hands a lot, and don’t touch your face. Maintain physical distance from other people. Yes, it’s hard to do, but take this advice to heart. That doesn’t mean you have to be holed up inside. It’s OK to go outside if you aren’t in a high traffic area.

SNT: What does that mean with respect to riding our bikes and other exercise?

MF: Do physical activity like riding your bike by yourself or only with others in your household. Maintain a physical distance from everyone else while doing it. Know your limits, and don’t put yourself at risk because the health system is taxed right now. There’s no reason to break your collarbone because this is the day you decided to huck the rock that you never hucked before. We all sacrifice now so we can do those kinds of things later.

Try to have some fun while you’re out there. It’s important to maintain good mental health throughout this. We’re all going to be called upon to support someone else who is sick or handling the stress differently, and we’re going to be in this for a while.

SNT: Should we be scared to go to the grocery store or to get take out food? What precautions should we take?

MF: A little fear isn’t bad, but you shouldn’t be frightened to go. Some fear encourages you to do the right thing and be cautious. We all need to go get food. Everyone has to go outside sometimes. Be thoughtful and considerate about how you do it to minimize your own risk and the risk to others. Avoid high traffic surfaces, and wash your hands. When you bring groceries back into the home, unpack things quickly and wash your hands right away. Don’t touch your face in between.

The same can be said for getting take-out food service. It’s ok to do it, just be thoughtful about it. You can pay and tip online then have the delivery person leave your food outside the door. Bring your food in, unpack it quickly and wash your hands right away. You want to break the chain of transmission of the virus from surface to hand to mouth, nose and eyes.

SNT: What do we do if we experience what we think are symptoms of COVID-19?

MF: If you start to feel ill, call your healthcare provider. Don’t just show up in person, so you don’t put others at risk. Call to find out first if they have testing capacity and the space for you. The truth is that most people will have a mild infection, and the only thing the doctor will do is manage your symptoms such as fever, cough, aches, etc. You can do this at home without experiencing serious disease. When we all take that approach, the people who progress toward serious disease and need immediate emergency attention can then be at the head of the line.

SNT: We’re getting mixed messages from politicians and government officials about how long strict measures for physical distancing will last. What’s your best guess based on the data and models about how this will unfold?

MF: To paraphrase Dr. Anthony Fauci, the virus will dictate the timeline. Calendar timelines are unlikely to be effective. The data will tell us when we are near the end.

We’re in the beginning of the beginning, and we’re looking to get to the end of the beginning. That’s when we’ll see the number of new cases per day slow down. The number of cases will still grow, but not as fast. That will be the first indication we started to get things under control.

Then, the number of new cases will start to decline. That’s the beginning of the end.

The end of the end can take almost forever. We don’t know if we’ll be living in a world where it will be part of our lives for the next several years. The severity is entirely dependent on what systems we put into place now.

We can handle this disease today with conventional medical therapy, and in the future, we’ll handle it with novel drugs that are being developed now. But drugs by themselves do not work. You need health systems that can test people and get them into care quickly. You need mechanisms for people to access testing and care rapidly. If we can get those in place, COVID-19 will be a manageable infection down the line.

What we’re trying to avoid right now is the massive flare up that fills all the hospital beds and ends with the healthcare system failing catastrophically. We have to build the health system we want six, nine... 12 months down the road. We’ll eventually develop treatments and a vaccine. We have the capacity to make the most out of our existing health systems to keep this thing from being debilitating both for the healthy and the sick.

SNT: We’ve heard talk about repeated waves of outbreaks over time. Is that likely and if so, why?

MF: It is likely. That’s in part because we’re doing everything we can now to minimize the size of the first outbreak. That means lots of people are still out there to get infected later. That’s fundamentally how multiple waves happen. It’s why it’s important to use the time we’re buying in the first wave to quash the second wave when it happens. We got caught off guard on the first wave. If we’re not prepared for the second wave, it’s completely on us. We’re buying time now to prevent the second wave.

SNT: What can we learn from other countries who are ahead of us in the progression--like China and Italy? Is it too late to implement what we’ve learned?

MF: Boy, I hope it’s not too late. We’re looking at those countries who are ahead of us to guide what the risks are. Italy has been held up as a worst case scenario. But that’s unfair because parts of Italy were rapidly overwhelmed, and others have been largely spared because they were proactive. Some places got behind the ball, and some were ahead of it.

China and South Korea enacted severe and, in some cases, too severe interventions. They also massively scaled up healthcare capacity. The reason that the outbreaks have largely ended there is because they invested in testing and getting people into care and treatment. An important thing about testing and testing quickly is that you can direct your efforts to the people who are sick and not to the people who are healthy. Right now we’re disproportionately affecting the healthy because we don’t know who the sick are. If we know who is and isn't healthy, we can target caring for those who are sick.

SNT: What will the coming out of the pandemic process look like?

MF: It’s going to be anxious. I wish I could say something better. We’re going to get to zero cases at some point. And then we have to maintain a period of vigilance to make sure it’s really zero. That’s tough if you have a virus with a high rate of asymptomatic disease. We’ll have to look for it hard. We have to invest in testing now so that when the numbers get low, we can still find it. If we’re not doing that level of testing, we’ll always be concerned that it will come back.

Given how broadly it is distributed around the world, it’ll probably still be somewhere else, and it could come back. We will have to invest in robust health systems that can mitigate flare ups. We don’t want to be shutting down the whole country all the time. We have to be able to contain future outbreaks. The upside is that most of the systems that we invest in will help keep people healthy anyway.

SNT: Will some parts of the U.S. will get back to “normal” faster than others?

MF: I don’t think so. I think we’re going to have to come out of it together as a country. We’re hoping that we can quash this locally at a point where not everybody got sick. If we are successful at doing that, a large number of people will still be able to get sick because they haven’t been previously infected. Even if New York gets over it faster than somewhere else, people move around a lot. The places that got hit first are not necessarily the first to go back to the bars. We’ll have to reintroduce “normal” everywhere.

SNT: What do we know about immunity after being infected?

MF: We’re just starting to learn. In animal models and in human follow-ups, there are antibodies that indicate protective immunity. That’s really good. That means that after you are infected, you should at least be protected in the short term.

SNT: Any parting thoughts?

MF: We should all be aware of the community impact of this virus. It will affect everyone differently--both physically and economically. Some of us have stable jobs and salaries while others will have financial, food and/or housing insecurity. We should all consider what we can do to support the businesses that we want to still be around when this is all over. We should support our employees to work from home if they can. We want to reduce financial and emotional stress in others whenever we have the capacity to do so. You might not know that someone was vulnerable until things happen. We have to do what we can as individuals to offer support to and protect those that are the most vulnerable.

Further information from Dr. Ferrari can be found in these videos and an interview he'd conducted with NPR: