Social Distancing and Waiting Until It’s Safe Enough to Re-open

“US governors seeking to relax public health restrictions on the activity of people and businesses are acting prematurely and risk inciting a second, more damaging wave of infections from the coronavirus pandemic, public health experts have warned.” — The Guardian

“How to proceed? The U.S. urgently needs to restart, but no economy can function if an infectious disease like COVID-19 continues to sicken the workforce and keep customers to a trickle.”  — From an Article in Time compiling expert recommendations on how to restart the U.S. economy in the midst of a mass COVID-19 outbreak.

“Even in the hardest-hit places [in the U.S.], fewer than 1 in 10 people have been infected. So not only could COVID-19 come roaring back, but it could get five times or close to 10 times worse than it is now. The only way forward is to suppress cases and clusters of cases rapidly.” — Dr. Tom Frieden, former director of the U.S. Centers for Disease Control and Prevention (CDC)

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Let’s acknowledge one simple fact. Staying at home to fight a pandemic and to save hundreds of thousands to millions of lives is in itself painful. It can be hard for many reasons. It’s necessary. But, historically, it has been fraught with social difficulty. So as we resolve ourselves not to waver, we should not disparage how difficult the task is.

It comes with economic sacrifice. Preventing loss that would have been even worse if a deadly illness broke out more fully, amplified, and overwhelmed both society-based and healthcare-related systems. But it is sacrifice nonetheless.

It results in social isolation that many have difficulty tolerating. It can be stuffy, stultifying, even claustrophobic. Many of us rely on our contacts with our fellow human beings to maintain emotionally healthy lives. Stay at home thus costs us in less quantitative but very palpable ways for this reason.

In a larger sense it grinds down the body of the human world. It puts civilization into a self-induced collapse into coma. For these reasons and others — it is hard. It requires an effort of collective will to maintain. And it can become tempting to fall prey to messages of false confidence during times of intense social distancing and isolation aimed at saving lives.

Social Distancing — a Sometimes-Necessary Improvement on a Response to Deadly Illnesses that Goes Back Centuries

Historically, though effective, such isolation to prevent death from illness has been difficult to maintain, tricky to time, and vulnerable to resurgent loss of life resulting from the erosion of societal will to maintain isolation for a period long enough to keep deadly illnesses under control. In the mid-to-late 20th Century, as vaccines, antibiotics, and other pharmaceutical treatments became more effective at controlling illness, reduction of illness-resulting contacts became mostly a secondary tool in preventing loss of life. But with the emergence of novel illnesses like HIV, Ebola, and SARS, various forms of isolation and infection prevention through reducing harmful contacts returned. And to prevent loss of life on a far greater scale, social distancing itself has re-emerged during the time of COVID-19 (SARS-CoV-2).

Seattle Police Wearing Masks During the 1918 Flu Pandemic

Seattle police wearing masks during the 1918 flu pandemic. Those who didn’t wear masks at the time were called ‘mask slackers.’ In addition to wearing masks, many cities conducted lockdowns in an attempt to prevent illness spread. Early relaxation of lockdowns at the time often resulted in surging rates of infection. Image source: Seattle Police, 1918.

When was the last time society really isolated itself in way similar to the extent we see today during COVID-19? We have to go back to the various quarantine and lock-down strategies deployed during the 1918-1919 flu pandemic a century ago. Back then, events were similar. Masks became widespread. The illness presented a high virulence and risk of loss of life. Cities enacted lockdown proceedures. Some of them opened too soon without other effective disease interventions only to see the deadly illness re-surge in subsequent waves of infection.

But isolation and quarantine itself has roots that reach back much further. All the way to the days of the Black Plague in Italy during the 14th Century. Even then, health ministers had learned that this disease was coming to Venice on ships (specifically from a disease reservoir in infected rats and fleas, but they didn’t know that at the time). They imposed a 40 day wait period or quarantine — derived from the Italian word quaranta for the number 40 — for ships coming to their port in order to contain the spread of the illness.

Other isolation measures were established due to suspicions that the disease was carried from person to person on a ‘pestilential air.’ Captains from ships with plague were spoken to through a window to reduce contact. Infected persons were sent to a quarantine island. All measures enacted to protect the larger population of Venice.

Plague is more specifically transmitted by flea bites, body fluid contact or the consumption of infected animal tissue in the case of bubonic plague, and through infected droplets spread by cough in the case of pnemonic plague. Still, the archaic form of social distancing in Italy was useful in containing and lessening disease outbreaks in the absence of effective pharmaceutical interventions in the form of vaccinations or treatments. It later became widespread across Europe and the world.

These responses come with a cost. They are disruptive. They force people into states of detainment — voluntary or otherwise. Movements are restricted. During quarantines, we lose contacts with our fellows. According to an article on The Science of Social Distancing published on The American Society for Microbiology website:

An organized community response to infection is most critical in the absence of pharmaceutical treatments and cures, but varying levels of political, ethical and socioeconomic controversy have long accompanied these practices.

As difficult as it can be, absent other measures to prevent illness spread, to cure lethal and virulent illness, or to substantially reduce their harmful impact, social distancing, isolation, and quarantine can become necessary to save lives.

How Social Distancing Measures Have Reduced Loss of Life — Reduced Spread, Amplification Prevented, Hospital Supports Preserved

Social distancing works on a number of levels. The first is that it reduces infections by preventing the contacts needed for an illness to spread. Reduced infection rate in a virulent illness like COVID-19 also generally reduces death. It’s basic math that if an illness that has an average case fatality rate of 3.4 percent, as indicated by WHO, is limited to say 100,000 cases where they would otherwise be 1 million, then the total number of deaths is reduced by more than 30,000. For the U.S., the observed case fatality rate is unfortunately much higher than this WHO stated average — on April 30 at around 5.78 percent. This might be due to the fact that the WHO estimate for confirmed case fatality is low, or it might be due to the fact that the U.S. is detecting more life threatening cases, or it may be due to the fact that in places like New York City, the disease has been given space to amplify, to become more deadly. Likely, the presently higher U.S. confirmed case fatality rate is due to some combination of these factors and related considerations. But it is also worth noting that the U.S. case fatality rate is still below a present global average of around 7.1 percent and China’s case fatality rate of around 6 percent (April 30, 2020 figures).

As a second factor, social distancing reduces the ability of an illness like COVID-19 to become more deadly through pure density of infectious particles alone. For if such an illness spreads enough, its deadliness can amplify. What this means is that so many people become ill that infectious material becomes very common in the local environment. This produces generally larger doses of disease when people become exposed. It can produce both multiple lower level exposures that result in a higher infectious dose load over time and the increased potential for much larger single infectious dose loads during encounters with the infectious agent. And larger doses of harmful agents are often more lethal. With COVID-19 there is evidence that this is the case. A recent New York Times piece written by Dr. Rabinowtz and Dr. Bartman noted — “As with any other poison, viruses are usually deadlier in larger amounts.”

The third way social distancing works to reduce lethality in a modern society is by protecting life-saving hospital support. In the instance of COVID-19, ICU cases presently (April 30, 2020) show about a 50 percent mortality. But without ICU care made available, almost all those people needing that support would perish. In other words, people are put on breathing machines because there is a period of time in which the illness removes their ability to breathe on their own — requiring advanced life support. Remove that advanced level of care for many because the need overwhelms availability and the result is that the death rate from the illness again jumps higher.

Hundreds of Thousands Saved

As a result, present social distancing measures in the U.S. and around the world have together reduced loss of life by tens to hundreds of thousands or more. In the U.S. alone, a terrible early national response by the Trump Administration to COVID-19 resulted in widespread weaknesses in infectious disease defense enabling widespread outbreaks, at least some viral amplification, and a pathway that according to CDC would have resulted in between 1.5 and 2.2 million deaths through August without social distancing and stay at home policies. Actions primarily taken by governors across the U.S. in response to rising outbreaks, great risk of loss of life, and related public fear. Now, after this wave of aggressive social distancing, we have the potential to reasonably limit deaths to around 90,000 to 240,000 over the same timeframe (through August 2020). If we manage things responsibly and we are lucky. For the month of April alone, deaths have likely been reduced from a potential of around 150,000 to 350,000 to the present range of around 56,000 to 90,000 when excess deaths likely caused by COVID-19 are included (we won’t know fully for a while due to the up to a two month lag in death certificate completion). This is still a terrible toll. But what we can say is that it would have been much worse if we hadn’t acted.

(Governor Whitmer of a Michigan slammed by COVID-19 cases extended her stay at home order until mid-May last week. This week, armed protesters bringing with them the threat of political violence pushed to force Michigan to re-open early, threatening public health.)

For a certainty, there are a number of the irrational, harmful, and downright terrorist-like armed ‘protests’ coming from the Trump-backing right-wing echo-chamber at present holding ‘make America sicker again’ rallies. Saying just the opposite — that social distancing didn’t work. That it wasn’t needed. That herd immunity alone would have created the reduction in death rates that we have seen because we acted (see experts blast right wing supported herd immunity theory). To, as with climate change denial, generate anti-factually premised arguments that if listened to create false perceptions, false confidence and that risk degrading the effectiveness of action supported by medical professionals and disease fighting experts. Now, these same voices threaten to erode rationality and turn us away from the implementation of life-saving methods as we look toward reopening in a responsible, measured fashion. One more likely to actually help the economy that, itself, relies on health and public confidence in health to function.

Reopening Responsibly Without Proven Pharmaceutical Interventions — Testing, Tracing, Isolating

Fortunately, for modern societies, absent proven effective vaccines or treatments, we still have methods at our disposal for reducing disease outbreaks and limiting spread outside of and in conjunction with social distancing. I touched on these methods in the earlier chapters about South Korea’s effective early COVID-19 containment operation and in the chapter on COVID-19 testing in the United States.

As we look to start reopening, testing, contacts tracing and isolation again, according to disease experts, becomes necessary to ensure the safety of populations. CDC had identified this need as early as mid April stating:

The director for the Centers for Disease Control and Prevention said Monday [April 13] that in order for the country to reopen, swift testing for people who have the virus and for people who might be immune to the virus will need to be available.

However, we are still seeing notable limits in the number of available high-accuracy test kits relative to the number of infections. Present test rates of around 220,000 per day, while numerically high, is still likely not adequate given that the U.S. population is about 330 million (a ten to one negative to positive result is recommended by experts as a benchmark, the U.S. is at 6 to 1 at present suggesting a need to almost double the daily testing rate), that the viral load is a high enough fraction of the present population to represent a serious threat of much larger outbreaks if left unchecked, that the virus is so highly transmissible, and that people possessing antibodies have at best an uncertain immunity at present.

US Testing

To effectively manage present levels of infection, U.S. testing capacity needs to about double. However, if early or slipshod reopening results in expanded cases, the ability for the U.S. to test, trace, and isolate will again fall behind. Image source: Our World in Data.

As a result, COVID-19 presents a number of challenges for governors wishing to reopen states. The first is that the mentioned viral load in the U.S. now is quite high. We have more than a million confirmed cases as of April 30. We are looking at around 860,000 active cases at present. Dividing the active cases by the existing population shows that about 1 in 400 people have been detected with illness infection in the United States. In addition, COVID-19 is known to produce asymptomatic infections. These asymptomatic cases are still most often in addition to the detected fraction because the continued lower availability of test kits in the U.S. means that most tests are still given to people with symptoms. Asymptomatic cases are also suspected of being transmissible carriers of COVID-19. And the asymptomatic fraction for this illness, based on recent studies, may be rather large, comparable to seasonal flu (which ranges from 12 to 85 percent in virological and serological studies but is typically cited at 20 to 50 percent).

Such a large viral load in the general populace, uncertain levels of infected immunity with a potential for reinfection, and evidence of at least a decent-sized asymptomatic fraction presents a quandry for health officials looking to safely reopen states and to protect the general population. That said, and given what we know, we can work to effectively deploy resources to protect the public as states look to start re-opening.

Reopening Under CDC Guidance and Aggressively Taking on the Virus — Setting Public Safety as the Top Priority

The first key step, according to health experts, is to not re-open while viral cases and hospital cases are still expanding. Reopening should occur according to CDC guidelines following a two week reduction in cases. Since cases are still at plateau or are still expanding in many states, this would suggest that rational re-opening timeframes for most regions run from mid-May to mid-June. However, this range is provisional based on expected viral drop-off rates. And COVID-19 has tended to linger for longer than expected in some regions. Opening earlier risks larger outbreaks. And the history of opening while cases are still rising without other effective interventions is full of stark examples (see lack of quarantines allowed 1918 flu to spread and grow).

The second step is to, according to CDC, widely deploy available testing. Ideally, this testing will be broad enough to effectively detect, trace and isolate a majority of the cases. CDC guidance appears to assume it will be. However, given that the U.S. is not at the recommended 10 to 1 negative to positive test threshold, there is evidence that test shortages are still an issue. Therefore, like Maryland Governor Larry Hogan directed yesterday, testing resources may need to be deployed in a more targeted manner. For example, Hogan indicated that highest risk case clusters are occurring in meat packing facilities and in nursing homes.

As an example, Hogan’s action of aggressively deploying available testing, contacts tracing and isolation for those hot spots produces a greater opportunity to reduce risk of expanding infection and loss of life. Also Maryland’s example of setting up drive-through testing centers when test kits are available for people with symptoms, along lines similar to those of the South Korea model, provides a secondary, targeted containment infrastructure. It is worth noting that Hogan is departing from his earlier tact of adhering strongly to expert advise on reopening timelines. Hogan presently plans to reopen as soon as hospitalized cases plateau for two weeks — rather than according to the two week case reduction recommendation by CDC. This particular facet does increase risk to Marylanders.

In the absence of available test kits, temperature screening in workplace and other environments is an available option to increase infection contaiment. This is a broader brush approach. And it does not detact the assymptomatic fraction of cases. But it does help to contain the most highly infectious instances. CDC provides a useful set of guidelines for conducting such screening here.

In addition, provision of protective barriers, increased ventilation, and face coverings for persons in any re-opened public work environments according to CDC guidance would help to limit contacts and disease spread. People in workplaces, social gatherings, using mass transportation, and in many aspects of life and work would help to prevent loss of life during any reopening scenario by following such CDC guidance as well.

Other Considerations — Start and Stop, Effective Communication, Doing Real Work to Build Trust

Finally, considering the continuing great risk to public health, reopening may need to start and stop. Meaning that if infections increase, reopened sectors may need to shut down again to limit disease spread. These response shut-downs could be total or staggered — escalating and de-escalating based on observed changes in outbreaks.

Overall, the idea is to respond to the virus in a smart, flexible manner that both protects the public and generates the real confidence needed to get the economy up and running. Listening to infectious disease expects, healthcare leaders, CDC, local leaders and the general public will be crucial in this regard. On the one end, specific knowledge and concerns provided by health and disease experts saves lives, and on the other end, local leaders and the public will give an understanding as to whether communities and individuals feel they have been protected during any re-opening. This communication with the public both gauges public confidence, which is necessary in any reopening, and increases state leadership’s responsibility to protect lives.

Daily U.S. Deaths COVID-19

Daily U.S. COVID-19 deaths are on a long plateau. Whether they go up or down depends in large part on if reopening is rushed and botched, or cautious and effective. Image source: Worldometers.

Potentially helpful infectious disease treatments and new pharmaceutical interventions may aid in any reopening strategy by reducing stress on hospitals, potentially reducing loss of life, and helping to increase public confidence. But at this time it is important to consider that none of the present potential interventions, as yet, is a silver bullet. So the effectiveness of any new treatments should not be over-stated in a way that undermines trust.

We are entering a tricky time fraught with danger. But if we are wise, cautious, and fortunate, we may begin to climb out of this terrible pandemic. Hasty, reactionary responses that ignore the advice of health experts, however, carry with them a high risk of worsened tragedy and even more terrible loss of life than we have already experienced.

Up Next: A Possible Vaccine, But When?

The Trouble With Testing Part 1 — “No Responsibility at All”

“The White House is now home to an inattentive, conspiracy-minded president. We should not underestimate what that could mean.” — The Atlantic in a special report on U.S. pandemic preparedness during the July/August 2018 issue

“Anybody that wants a test can get a test. That’s what the bottom line is… and the tests are all perfect, like the letter was perfect. The transcription was perfect, right?” — Donald Trump on March 6 as U.S. was suffering a major shortage of COVID-19 test kits. 

“I take no responsibility at all.” — Donald Trump when asked if he felt any responsibility for the persistent lags in U.S. testing capability on March 13. 

“President Trump continues to falsely state that everyone who needs a COVID-19 test can get one.” — In an NPR interview conducted on April 2. 

“Two and a half months after the first reported coronavirus case in the US, America still doesn’t have the capacity that it needs to track all cases…” — Vox.

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The need for testing during a virus epidemic is directly related to the number of infected persons. If the outbreak is small, the need for testing is also proportionately smaller. And if the outbreak is large, then the need for testing is subsequently much larger.

Ironically, the more testing happens early on, the more cases are identified early on, the more contacts are traced and isolated early on, the more the virus is ultimately contained and the lower the follow-on need for tests. The inverse is also true. The less testing, identifying, and containing of pandemic illness early on, the more tests will later be needed.

A failure to test, trace and isolate in the U.S. early on resulted in a massive COVID-19 outbreak necessitating nationwide mitigation. 1 in 5 people tested in the U.S. are still showing up as positive as of April 20th — indicating that tests are generally still occurring only for high risk persons and not for the broader population. Image source: Our World in Data.

Because less testing, identification and containment means an illness like COVID-19 can expand undetected, exponentially, and with far less constraint. Each failure to respond to this nasty disease pushes us up the scale in the need for a still greater response in the form of testing, isolation, sanitation, and ultimately mitigation. And if leadership is incapable of providing that response in a continuous escalation, then we end up with an ever-expanding disaster. That’s what we face here in the U.S. Because here a national leadership under Trump that utterly lacks responsibility is showing its dramatic incapacity.

A Question of Responsibility

What is responsibility? At its root — response. In a disaster, swift, decisive, and effective response is what it takes to prevent an expanding and uncontainable cascade of harm, economic loss, and loss of life. Without leadership responsibility, a sense of duty to the persons under leadership’s charge and a willingness to answer to others, to positively absorb criticism, to act, to overcome barriers in order to make effective action possible, then crisis and disaster response itself will be set up to fail.

In the context of COVID-19, U.S. leadership failure by a corrupt and incompetent Trump Administration has weighed heavily in loss of life and well-being. Specifically, the Administration’s failure to take the responsibility necessary to provide the tests Americans need has been a critical aspect of this failure.

Test Development Timeline in a Global Context

Unlike South Korea which took swift action and outran global COVID-19 testing capability, the U.S. response under Trump in the form of deploying viable test kits, has lagged it.

On December 30 and 31 of 2019, China and WHO had identified pnemonia-like cases of a new illness. By January 10-12 of 2020, China released the new disease (later called SARS-CoV-2 for the virus or COVID-19 for the illness the virus causes) genome to the world. Within just a few days, German scientists, using SARS-CoV as a reference, had developed a test that could identify a unique portion of the SARS-CoV-2 virus’s DNA. On January 17, the World Health Organization (WHO) adopted the German-based test, published the guidelines for developing the test, and began working with private companies to rapidly produce those tests and distribute them. As other agencies developed new tests, WHO would also publicly provide the new formulas. For example, WHO published China’s test development formula one week later on January 24.

The importance of WHO action at this stage was threefold. First, it provided information on how to manufacture an effective test. In other words, any country could take the WHO-provided information and use it to mass produce its own tests. Like South Korea, they could then independently coordinate with medical industry to get the production chain rolling. Unlike South Korea, they no longer needed to independently develop one. A test formula was now publicly available. Second, the WHO began to manufacture test kits to send out to other nations who requested them. These manufactured kits provided physical samples of the published testing formula — making it easier for manufacturers in other countries to validate and reproduce. Third, WHO served as an agency that mass produced tests. This helped to provide tests to those who were unable to provide for themselves. By March 16, two months later, WHO alone had produced 1,500,000 tests and sent kits out to 120 countries.

The gene assay of SARS-CoV provided by Olfert Landt to the World Health Organization in January. This assay would result in an easily producible test that many nations would use to contain their COVID-19 outbreak. Image source: WHO.

Independently, the German firm that provided the first test protocol adopted by WHO was also shipping out tests to other countries. In mid-January, New Zealand, who decided the WHO-published test formula was good enough and the need for more immediate access to tests was greater than the need to independently produce one at home, ordered the Germany-developed kits. The kits were subsequently shipped. And New Zealand was provided with tests ahead of the outbreak that later occurred. In other words — they were prepared. Australia and a number of other countries made the same decision — also ordering their test kits from overseas. Olfert Landt’s firm, the German Agency that developed the first COVID-19 test protocol adopted by WHO, alone was shipping out 1,500,000 tests per week by late February of 2020.

U.S. — All Testing Eggs Slow-Walked into one Trump-Shrunken Basket

In the U.S., the Centers for Disease Control, a crucial public health protection organ, had long suffered budget cuts and diminishment under Trump. As noted before, each of Trump’s budgets had requested reduced funding for CDC and his attacks on the Affordable Care Act also degraded U.S. disease fighting capability. His removal of Obama’s Pandemic Task Force had cut off a federal limb that could have helped stop the virus in its tracks overseas, but if it did get out could have also coordinated infectious disease response at home and abroad, cut red tape, and sped the availability of materials such as test kits for the U.S. public.

Perhaps as equally pivotal, though, was Trump’s choice of director — Robert Redfield — to head CDC. Redfield, unlike many of Trump’s appointees, was certainly a professional with many years of experience in his field. One who spent 30 years researching HIV and for 20 years served in the U.S. Army Medical Corps. Redfield was, arguably though, far from a great choice to head the agency responsible for fighting disease in the U.S. He was embroiled in a controversy over an HIV vaccination trial in the 1990s in which he was accused of manipulating data. Redfield has also been criticized for allowing his strong religious beliefs to interfere with his medical views. Peter Lurie from the Center for Science in the Public Interest, a consumer advocacy group expressed this concern about Redfield’s appointment: “What one would get in Robert Redfield is a sloppy scientist with a long history of scientific misconduct and an extreme religious agenda.”

In choosing the controversial Redfield, Trump also passed over Anne Schuchat — a career public servant whose experience dealing with Anthrax in the U.S., Ebola in West Africa, and SARS in China made her an ideal choice for CDC head. In other words, an infectious disease expert with exactly the kind of experience to handle an illness like COVID-19. That’s what the people of the United States didn’t get from Trump. What we got was something that we’ve come to expect from a corrupt and incompetent Administration — at best a political appointee with professional credentials but also possessed of a questionable and often partisan-charged past, at worst the same but with no professional standing whatsoever.

As it happened, on the same day that WHO had published Olfert Landt’s test kit formula on its website, January 17, a sapped CDC in the U.S. announced that it had developed its own preliminary test for COVID-19. They’d decided to work on their own test. This decision was guided in part by regulation — and much of it for good reason. We didn’t want to open the door to fraudulent tests. But it was also a decision that occurred in the context of a global health emergency. And leadership from the top could have worked to ensure the protective needs of regulation were adhered to while still providing back-up options if the CDC-sponsored test kit development occurred too slowly or didn’t produce a usable test soon enough.

In other words, they could have cut red tape to enable medical industry in the U.S. to produce coordinate tests. Like South Korea, they could have called together industry heads and provided organization and guidance. Something a dedicated pandemic response team, had it been in place, could have helped to accomplish. Something a CDC head with novel pandemic chops like Anne Schuchat would have recognized the need for. CDC could have worked to validate those tests in conjunction with its own test. It could have used one of a number of WHO-validated formulas for these coordinate tests. It could have set up teams to work to validate multiple sets of tests to determine which ones were effective. It could have worked to set up contingency surge production if more tests were needed (as happened in South Korea and elsewhere).

The bio of Anne Schuchat — the kind of infectious disease expert that the U.S. is capable of fielding to head an effective pandemic response. The kind of expert the Trump Administration has repeatedly passed over in favor of less effective leaders. Image source: CDC.

Such a layered strategy did not develop at CDC under Redfield as head. At first, and for many weeks after, the decision by leadership was to support one testing regime and then to in a laissez faire way, ignore the fact that other agencies such as FDA ended up using existing regulation to defend it and to (unintentionally) stymie the independent development of effective tests in the U.S. In other words, through lack of response adequate to the threat of COVID-19, Trump’s CDC head put all their testing eggs into one basket.

Making Our Own Unluck

It all could have still worked out. The U.S. could have been lucky. The CDC test could have worked effectively. It could have arrived in time to help stop the virus. It could have arrived in enough numbers to meet the testing need. It could have been targeted to the regions that needed it most. Trump’s Redfield CDC hadn’t increased their likelihood of that success, though. They had greatly increased the opportunity for failure. And given that self-infliction of a worsened set of odds, things did not go well.

Development of the CDC test notably lagged behind the rest of the world. By January 21, the U.S. saw its first confirmed case of COVID-19. It was of a man who’d flown back from Wuhan, China and entered the U.S. on January 15. But it took another week — until January 28th for the CDC to provide its own test kit formula to WHO — 11 days later than Germany, four days later than China, and weeks after South Korea had developed an effective test protocol. Fully two weeks after the virus had arrived on U.S. shores.

It wasn’t until February 5 — fully 19 days after CDC’s first test protocol was announced — that a CDC under Trump had shipped 200 test kits to more than 100 public health labs across the U.S. These tests were enough to test 60,000 – 80,000 people if the kits proved effective. By the same time, WHO had shipped 250,000 tests that had already been validated. Globally, on February 5, confirmed cases had risen to above 28,000. In the U.S., 12 cases had been confirmed with cases springing up Washington State, Illinois, Wisconsin, California, Massachusetts, and Arizona. Given what we know about COVID-19, actual numbers were probably already much greater than these early confirmations indicated.

The virus had arrived on U.S. shores and CDC had scrambled to send out these test kits. But the test deployment would ultimately prove to be seriously problematic. The trouble with these U.S. tests ended up being four-fold. First, that they had not yet (by February 5) been validated and many would later prove useless. Second, there weren’t enough to meet demand. Third, many came too late. And fourth, test kit distribution was not targeted or weighted to the regions of highest need. Why the U.S. CDC response was so much slower and so poorly coordinated compared to those of other nations has not fully been explained. Nor has it been fully explained why many of the tests that CDC ultimately provided would fail. But this failure was arguably a major reason why COVID-19 would break out to such a great extent in the U.S. Why the U.S. would experience the worst first wave outbreak of this novel deadly illness. Because what ultimately happened was a serious failure to contain the illness once it reached our shores. To perform that detection, contacts tracing and isolation that was proving so useful in places like South Korea.

So by early February, CDC had shipped out about 200 test kits to public health labs across the country. Each kit contained enough material to test between 300 to 400 patients. But because kits were evenly distributed, places with much higher populations, places like public health labs in New York City which would later experience a devastating outbreak, only received enough testing material to test between 300-400 patients at that time. That’s 300-400 tests for a public health lab serving a city of 8.4 million souls.

According to a report from Kaiser:

The kits were distributed roughly equally to locales in all 50 states. That decision presaged weeks of chaos, in which the availability of COVID-19 tests seemed oddly out of sync with where testing was needed.

Another problem was that the test kits that were shipped out often proved faulty — lacking critical components that hobbled kits ability to produce results. So from February 5 to mid February — for about ten days or so — public health labs across the country were put in the position where they needed to validate CDC test kits. And, in most cases, the validation of a useful kit did not occur. By mid-February only about six public health labs had access to reliable tests. But the Trump-appointed CDC director Robert Redfield was at the time entrenched, defending those tests. He insisted that CDC had developed a “very accurate test.”

Global distribution of COVID-19 cases on February 20, 2020. Image source: World Health Organization.

At this point the official number of cases stood at 15. But we know that those numbers were growing unchecked. Mainly because the CDC test kits would prove inadequate. On February 24th, U.S. confirmed cases had jumped to 53 and health experts were saying that community spread was happening in the U.S. On the same day, The Association of Public Health Laboratories sent a plea letter to the FDA asking if states could develop their own testing protocols independent of the CDC. In a few days, FDA reversed its previous position of defending CDC tests as a national standard and allowed states to begin producing their own tests. By February 29, after 43 days, the CDC tests had only been used 472 times. An astonishingly small number compared to the 60,000 to 80,000 that the original test kits should have represented. The U.S. confirmed case total stood at 68. But hundreds more people had already been infected by the illness in the U.S. We just didn’t have much of a way to know who or where because the CDC-backed testing regime ended up being so abysmal.

March Explosion

In the race between testing to track the illness and COVID-19’s in-built imperative to grow beyond our control in the U.S., the virus was winning. It had gotten a big head start of about a month and a half.

By early March, as the number of tests in the U.S. was finally starting to expand, in large part due to rapid production of tests within states and independent of the Trump-hobbled CDC, U.S. confirmed case totals were rapidly shooting upwards. On March 7, confirmed U.S. cases had hit 435. Redfield on the same day noted about the CDC tests: “We found that, in some of the states, it didn’t work. We figured out why. I don’t consider that a fault. I consider that doing quality control. I consider that success.”

By the end of March the U.S. COVID-19 case total would be the largest in the world. This would necessitate a nationwide lockdown as containment failed risking hundreds of thousands of deaths. Image source: Worldometers.

In one more week, confirmed cases would multiply nearly sevenfold — hitting 2,770 by March 14. Tests were finally starting to work and be produced in larger numbers. But for the U.S., a new worrying statistic was starting to become evident — the number of positive cases per test was notably high. In total about 1 out of every 4-5 people receiving a test were testing positive. This was due to the fact that the primary location for U.S. testing was hospitals and emergency rooms. The U.S. did not have widespread dedicated test facilities like South Korea. So most people who got a test were already very ill. All of this was an indication that the U.S. barely understood even the tip of the COVID-19 iceberg that the country was slamming up against.

By March 21, the number of COVID-19 cases had again exploded — hitting 24,345 or nearly ten times their number from the prior week. States such as Washington, New York, and California were testing thousands of people per day now. And a disturbing understanding of the U.S. disease curve was starting to emerge. A model produced by the Imperial College in London projected that as many as 2.2 million people in the U.S. could die if the U.S. did not move strongly to mitigate the spread of the virus.

Moving To Mitigation as Virus Outruns Containment in a Big Way

Unlike testing, contacts tracing, and isolation, mitigation involves serious constraints on activity within the impacted regions. In effect it would mean lockdowns or stay at home orders for much of the nation. A kind of freeze placed on society and economies in order to reduce mass loss of life. We say reduce, because the mass casualty event for the U.S. had already gotten well out of the bag. Tens of thousands would already lose their lives as a result. The question now was between tens of thousands and hundreds of thousands or millions along with a smashed U.S. hospital system.

By March 31, U.S. cases had again exploded to nearly 190,000. Even more tragically, already more than 4,000 souls had been lost due to the virus. A Trump Administration that had promised to provide 27 million tests by that time had only seen the U.S. testing 1 million. And a good portion of these tests were provided not by the CDC or the federal government under Trump, they were provided by states who were forced to scramble to fill the yawning vacuum of a failed federal testing, contacts tracing and isolation response.

Most U.S. states now have more than 1,000 COVID-19 cases. Many now have more than 10,000 cases. The U.S. total will likely near 1 million by the end of April. This massive outbreak has forced large scale mitigation in which most states remain under stay at home orders. Image source: CDC.

Now states would have to step in again. This time to provide the mitigation necessary to prevent about 2.2 million deaths across the U.S., California’s Gavin Newsom issued a stay at home order on March 19, New York’s Governor, Andrew Cuomo, made a similar order just a day later on March 20th, Washington State’s order came on March 25th, Maryland’s own stay at home order began on March 30th. By the end of March, fully 42 states had issued a stay at home policy. A policy that would remain in place for many weeks to come. Containment had failed in a dramatic way. Testing still lagged well behind the need. People who wanted tests still couldn’t get them. And as U.S. COVID-19 case numbers climbed toward 1 million in April, testing would continue to lag the need for it in most places.

The result was a full-on move to mitigate COVID-19’s spread. But the failure to provide enough tests would still haunt the U.S. And a new issue with testing would emerge as debates on how to restart a hobbled U.S. economy in the presence of a widespread and terrible virus that had wafted its way into all corners of our nation would again emerge. Sadly, this debate would continue to include a tone of irrational defiance to advice provided by experts and to the larger threat posed by a deadly and as yet incurable illness from the Trump Administration and its political supporters.

(UPDATED)

Up next: It’s Everywhere Now — COVID-19 A Global Viral Wildfire

 

 

Effective Containment — How South Korea’s First Coronavirus Wave was Halted

“Testing on its own will not stop the spread of SARS-CoV-2. Testing is part of a strategy. The World Health Organization recommends a combination of measures: rapid diagnosis and immediate isolation of cases, rigorous tracking and precautionary self-isolation of close contacts.” — COVID-19 Epidemic in Switzerland.

“South Korea has emerged as a sign of hope and a model to emulate. The country of 50 million appears to have greatly slowed its epidemic … Behind its success so far has been the most expansive and well-organized testing program in the world…” — Science Magazine.

“We acted like an army.” — Lee Sang-won, an infectious diseases expert at the South Korea Centers for Disease Control in a statement to Reuters.

*****

If U.S. leadership, under Trump, failed to initially prepare for, recognize, respond to, and effectively communicate to the public on the issue of COVID-19, there was a whole new set of failures surrounding the issue of infectious disease containment. Specifically involving the federal provision of enough tests to the public and to various infectious disease and emergency response agencies to stop a rapidly mounting COVID-19 threat. This failure is a part of the larger response failure by Trump and his administration. In particular, this containment failure was so crucial that it deserves a separate mention (next chapter).

But before we dig into the Trump Administration’s specific failure to provide the tests needed to conduct a successful disease outbreak containment, to gain an accurate picture of the disease outbreak during mitigation, or to provide any hope for an effective reopening of the economy following any successful mitigation, it’s helpful to look at the response of a nation that did manage a successful containment of COVID-19’s first wave. For a rapid response by South Korea, primarily through mass production of tests and subsequent contacts tracing and isolation, squashed what could have been a much more substantial first wave outbreak and ultimately managed to greatly limit new daily cases.

Testing and Containment

Detection and identification of cases, testing which according to CDC is an essential tool for detecting infectious agents, isolation of confirmed cases, contacts tracing, and isolation of confirmed contacts. In a single sentence, this basically defines a strategy of novel infectious disease outbreak containment (based on CDC’s after action reports on SARS response and CDC’s FAQ on SARS).

Epidemic phases and response

Epidemic phases and response interventions. Detection and containment are key responses. Availability of testing is critical for this phase of infectious disease response. Image source: World Health Organization.

It’s used when there’s a new illness outbreak that can’t be effectively treated or cured and when that illness represents a significant threat to life, well being, and a functioning society. In recent years, detection and containment was effective in halting both the first SARS outbreak in 2002 and 2003 and the major Ebola outbreak of 2013-2016. Containment is itself only as effective as the ability to positively identify — often best done through symptoms screening by astute healthcare professionals and testing — a majority of the active cases and to, through contacts tracing, identify each person contacted by the infected individual(s) and to isolate all those involved. If there are not enough tests to measure the number of people infected, if the information management resources do not exist to trace contacts, and if isolation of cases and contacts is not conducted in an effective manner, then containment is unlikely to succeed.

Containment should not be confused with mitigation. But it can be used alongside mitigation as part of a comprehensive strategy of disease response. Mitigation is a strategy to be used either in conjunction with containment of a large outbreak or when containment fails and a widespread outbreak begins to result in disease amplification and/or presents a threat to the effective functioning of healthcare infrastructure. Mitigation often involves social distancing — which is, in effect, the pre-emptive isolation of large sections of society to reduce contacts and to slow disease spread (we’ll talk more about mitigation in a later chapter).

Contact Tracing

Testing and positively identifying cases enables a second aspect of infectious disease containment — contact tracing. This practice can identify cases quickly and, in conjunction with isolation, prevent illness spread. Image source: CDC and CFCF.

Testing and containment is very important in its own right. It can stop an illness in its tracks. It can save thousands, tens of thousands, hundreds of thousands, or even millions of lives. In the present context of the COVID-19 pandemic, containment has succeeded where testing was widely available and when contacts tracing and isolation was conducted effectively. And in the worst outbreaks — such as in the U.S. — containment failed, in large part, due to lack of the capacity to conduct a large number of tests. This failure resulted in a greater outbreak which froze the economy and required large-scale mitigation to slow disease spread, maintain the ability of hospitals to function, and to reduce loss of life from millions to tens or hundreds of thousands.

South Korea — Learning Hard Lessons From MERS

The story of South Korea’s successful response to the first wave of COVID-19 pandemic begins back in 2015 when MERS was producing a global outbreak of new infectious illness. MERS was another novel disease similar to SARS in that it impacted the human respiratory system and resulted in high death rates. It emerged from yet another climatologically hot region — the Middle East. And MERS was still another novel coronavirus. One also with an ultimate origin in bats. However, MERS is thought to have a zoonosis due to harmful interactions between humans and camels. How MERS spread to camels from bats and then to humans remains somewhat unclear. Though it is thought that the consumption of poorly cooked camel meat is a likely vector for transfer of this new illness to human beings.

MERS was far more deadly than SARS — resulting in mortality in about 1/3 of those infected. Its geographic region of origin was the Middle East. And since the time when MERS was first identified in 2012, approximately 2519 individual infections have been reported on a global basis.

MERS MAP

A map of MERS transmission and outbreaks. Human outbreak areas shown in red and blue. Note South Korean outbreak in upper right. Image source: WHO.

In 2015, South Korea had its own tough brush with MERS. At the time, a South Korean businessman became ill after a trip to three countries in the Middle East. He sought treatment at three South Korean health facilities before he was diagnosed with MERS and put under isolation. But his contacts over the interim period ultimately resulted in 184 MERS infections within South Korea and 38 deaths. During this period, South Korea conducted a major response effort to contain the horrifying illness. The prospect of a major epidemic sent alarm signals through the country, slowed its economy, and traumatized the public. In response, South Korea produced a, then major, testing, contacts tracing, and isolation response in order to contain the illness. In the end, over 17,000 people were quarantined in an effort that ultimately quashed the outbreak.

Alertness, Training, and an Early Response

Pneumonia-type illnesses appear to have ingrained themselves on the collective consciousness of South Koreans during recent years. The 2015 MERS outbreak was viewed by many as a wake-up call. But the earlier 2002-2003 SARS outbreak and a general understanding of the risks of new coronaviruses appear to have made their cultural mark as well.

Back in December of 2019, according to reports from Reuters, two dozen top infectious disease experts in South Korea conducted a tabletop exercise. The scenario was oddly prophetic — a family becomes infected with a pnemonia-like illness after a trip to China. In the scenario, the new illness could have been a new form of influenza or a coronavirus like MERS or SARS. The exercise left its mark. And the lessons learned from it would be crucial to South Korea’s rapid escalation.

Just one month later, South Korea was organizing a response to an actual coronavirus pandemic emerging from China. And they were about as ready as they would ever be due to a combination of preparation, concern, and apparent luck.  On December 30 of 2019, China and WHO collected and analyzed samples of the novel coronavirus and then communicated first findings. And on January 4th, just five days later, South Korea’s infectious disease experts had access to a test methodology to positively identify COVID-19 cases. This was three days before China had genetically identified the new virus, it was five days before Chinese scientists uploaded a copy of SARS-CoV-2’s genome into an international repository. On January 9th they began lab testing for COVID-19.

They’d learned their lesson from MERS — quick response was absolutely necessary. And top experts still had the recent tabletop exercise fresh on their minds. But they still didn’t have a commercial, mass producible, test. The early testing methodology was slow. It could only manage a small number of cases at a time. As the disease began to rapidly expand in China, South Korean infectious disease experts feared they’d need something that was easily replicated on a mass scale.

On January 27th, South Korean infectious disease control personnel had detected just four cases of COVID-19 but they feared an epidemic. And their fears were rational. They’d experienced the explosive growth of MERS just a handful of years earlier and experts were starting to get hints that COVID-19 was a deceptive illness capable of both eluding detection and rapid expansion without widespread testing and isolation. On the same day, South Korean CDC officials summoned 20 heads of the nation’s medical industry. Their goal — turn South Korea’s lab test into a mass-produced, easy to use, diagnostic test. Just one week later, a diagnostic test produced by one of these companies was approved by South Korea’s CDC.

Lee Sang-won, infectious diseases expert at Korea’s Centers for Disease Control and Prevention, noted to Reuters — “We acted like an army.”

From Testing to Containment — South Korea’s Close Call

The problem with containing a disease like COVID-19 is that it is capable of seriously explosive spread. A single person infected with this illness who gets into a tightly packed setting with a large group or that moves rapidly from person-to-person can become what in disease parlance is known as a super-spreader. On February 18, just 11 days after South Korea had approved a commercially mass-producible test for COVID-19, a woman presenting symptoms who would represent South Korea’s 31st official case tested positive.

She was 61 years of age and, like many of us, she was a social person who delighted in her community. Part of her community was a rather large mega-church — the Shincheonji megachurch in Daegu, about 240 kilometers southeast of Seoul. When her contacts were traced it was found that she attended two services — one on February 9th and another on February 16th. At the time, she was already feeling slightly ill. In the church — 500 attendees would sit, tightly packed, through each 2 hour service.

South Korea Coronavirus Cases

Infection curve for South Korea shows a major spike in cases during late February and early March, then a rapid flattening that experts attribute to mass testing and isolation enabled by widely available tests for people with symptoms. Image Source: Worldometers.

From February 17 through 29, South Korea experienced an explosion of cases jumping from 31 to 3150. The vast majority of these new cases came from members of the Shincheonji megachurch. At this point, South Korea’s outbreak was the largest outside of mainland China. It was an outbreak that threatened to overwhelm the nation of 51 million people. South Korea’s 130 disease detectives were initially swamped by the Shincheonij-centered outbreak. More than 80 percent of patients with respiratory symptoms from this single outbreak were testing positive and the resources of South Korea’s traditional CDC response force was chiefly focused on this one cluster.

South Korea’s disease response teams were reeling. And without the earlier prep-work, they would have surely failed. As it was, South Korea just barely responded in time to prevent a much larger outbreak.

Responsible Governance Leads to Disease-Fighting Success

South Korea’s fast-tracked testing, contacts tracing and isolation system arrived in late February and rapidly expanded into March. This fast-tracking provided a key new disease response capability exactly when it was needed. By the end of February, just as its outbreak was ramping up, widespread road-side testing centers were opened. These centers were specifically set up to manage infected persons. Staff had personal protective equipment (PPE). They’d been trained in proper infection containment and sanitation protocols. And, in total, these centers were capable of testing thousands of people each day.

Drive Through Testing South Korea

One of South Korea’s many drive-through testing centers. At this location, healthcare professionals wearing personal protective equipment (PPE) administer a COVID-19 test. Image source: Government of South Korea.

In addition, specialized government isolation centers were opened for persons infected with COVID-19 — adding an outside capacity that reduced stress to hospitals. People who tested positive were required to download an app on their phone that traced their past movements and contacts. These contacts were also required to download the phone app and to self-isolate. Violators of the self-isolation policy were fined a 2,500 dollar equivalent.

This larger second line of defense enabled South Korea’s health officials to capture cases and conduct larger isolation outside of the initial disease cluster. A massive public health defense infrastructure that effectively sprang up overnight in response to the illness. One that ultimately prevented larger spread, wider sickness, increased illness amplification and death, and a need for even larger resource allocation to fight the disease. A national resource that would prove crucial.

Looking at South Korea’s infection curve, you can see how effective South Korea’s policy of rapid response containment has been. The results speak for themselves. They should count themselves fortunate for the responsiveness and responsibility displayed by their national government and leading healthcare professionals. Their first wave infection curve would have been much worse without it. It could have looked like Italy, or worse, the United States.

(UPDATED — Clarification on South Korea research testing timeline vs China’s COVID-19 research and coordination with WHO.)

Up Next: The Trouble With Testing Part 1 — “No Responsibility at All”

Ebola, Climate Change and Going Airborne — Merciless Outbreak Raises Fears

  • UN Warns of Remote Possibility Ebola Could Become Airborne
  • 3,330 dead and more than 7,100 infected during recent outbreak
  • 5 new infections every hour
  • One confirmed US case of Ebola in Texas, another suspected in Hawaii. Both air travelers from Africa.
  • US dispatches 1,400 troops to Liberia to aid in massive effort to contain the virus
  • Death rate for Ebola is 25-90 percent
  • Climate change only indirectly related to current outbreak

 

west-africa-distribution-map

(Current extent of Ebola outbreak in West Africa, according to CDC sources. Image source: Google/CDC)

As of this July of 2014, the number of recorded Ebola deaths worldwide since the mid 1970s was a little over 1,500 with less than 3,000 infections. That was before a massive outbreak centering on Sierra Leone in Africa killed more than 3,300 and infected more than 7,100.

Today, the estimated rate of infection is about 5 persons every hour. Persons infected with the virus have come as far as Texas in the United States prompting the immediate US quarantine of over 100 people thought to have been exposed. In total, this outbreak is likely to infect more than 20,000. And that’s if a massive international effort to stop the virus is effective.

It’s an effort that includes all the resources the UN has available to fight and contain diseases. An effort that has resulted in the mobilization of 1,400 US Military troops from Fort Campbell Kentucky bound for the West African hot zone.

Ebola — A Deadly Killer

Some years ago, I managed the editing of a Jane’s emergency response guide called The Chem-bio Handbook. The handbook was a compilation of information from leading experts about the world’s most deadly poisons and diseases. A quick reference guide for first responders unfortunate enough to have to deal with the most nightmarish toxins and infections dreamed up by nature or humankind.

Among these, Ebola was certainly one of the most feared and mysterious.

Ebola progression

(Ebola progression of symptoms. Image source: CDC — Ebola.)

It was transferred by contact with bodily fluids — blood, sweat, saliva, semen, excrement. It waited latent in the body for between two and twenty one days before first flaring into flu-like symptoms. Headache, fever, sore throat, weakness, muscle pain. These indistinct symptoms could go along with a hundred other illnesses. But after some days, Ebola went hemorrhagic. At this point vomiting, diarrhea, rash, failing liver and kidneys, and internal and external bleeding displayed Ebola’s all too familiar and terrifying call signs.

In the end, the disease claimed between 25 and 90 percent of all those who fell ill with it. A death rate that is among the worst of the worst for any disease now active on the Earth.

Treatment for the illness is primarily limited to supportive care and isolating the patient to prevent the infection from spreading. But during recent years a serum derived from the blood of victims who have survived the illness has provided some hope for raising recovery rates. Investigation for an effective vaccine is ongoing.

Rapid Mutation

One issue with the current strain of Ebola now impacting Seirra Leone and broader Africa is that it is a rapid mutator. The strain separated from the standard forms of Ebola seen in humans about ten years ago. Since that time, the virus has accumulated about 395 mutations. After leaping back to humans this summer, the virus had accumulated 5o new mutations in just one month.

The problem with rapid mutation is that it gives the virus a chance to become more virulent. In the worst case, some researchers and international officials fear that the virus could become airborne.

Today, Anthony Banbury, the UN Secretary General’s Special Representative, raised these dire concerns in public stating:

‘The longer [Ebola] moves around in human hosts in the virulent melting pot that is West Africa, the more chances increase that it could mutate. [Airborne contagion] is a nightmare scenario, and unlikely, but it can’t be ruled out.’

Most researchers consider the risk for such a transfer from fluid-borne to airborne infection for any illness, even a rapid mutator, to be very low. So it is rather odd that the UN’s special representative would voice these fears without special cause for concern.

Highest Risk Event Ever

This high level of concern may well be related to the terrors UN and international aid workers are witnessing on the ground.

Mr. Banbury, who has worked with the UN on the issue of dangerous and infectious diseases, wars, natural disasters and other extreme events since 1988 appeared both horrified and taken aback by the ferocity of the current outbreak:

“We have never seen anything like it. In a career working in these kinds of situations, wars, natural disasters – I have never seen anything as serious or dangerous or high risk as this one. I’ve heard other people saying this as well, senior figures who are not being alarmist. Behind closed doors, they are saying they have never seen anything as bad,” he said.

In order to contain the outbreak, the international community is scrambling to set up thousands of clinics and isolation centers throughout affected regions. The idea is to isolate more than 70 percent of the infected persons to prevent the virus from making yet another explosive advance. Ultimately, the goal is to get a reduction in cases after a strong three-month-long response:

“We intend to see a significant improvement in the 30 to 60-day window, so that by 90 days the curve is headed in the right direction. We are putting resources in place very fast, and we will continue to flow in. It is not all there at the moment,” Mr Banbury said. “That’s the theory and that’s the plan. If it spreads in an urban setting, then it’s a different story.”

“I would not say I am confident we will succeed [in the 90-day plan] given the absolutely merciless numbers of the spread and what needs to be done to get it under control. These are extremely, extremely ambitious targets, set by doctors. We are blowing down bureaucratic barriers to get things done…but I don’t know if it will be enough…I would not want to give the impression that we can wave a magic wand.”

Climate Change an Indirect Factor

Back in August, both Newsweek and MSNBC provided speculative stories raising the possibility that the current Ebola outbreak was directly related to climate change. But unlike vector driven illnesses such as Cholera and Malaria, it is very difficult to pin down a specific link between Ebola and the human-caused warming of the globe.

Related factors such increasing poverty and hunger driving humans to consume more bush meat and therefore expose themselves to higher risk of contracting an animal-borne infection such as Ebola are likely at play. And larger factors such as increasing human population density, global travel, and human concentration into urban centers all likely increase risks linked to Ebola. But the heat driven influences on Ebola are far less than expanding the range of Malaria bearing mosquitos or a proliferation of flooding events greatly magnifying the risk of Cholera outbreaks.

It is worth noting, however, that diseases, overall, tend to become more virulent with warming as pathogen killing cold spells are retreating further and further poleward.

Links:

Please See the CDC Website for Official Information on Ebola and for Frequent Updates

UN Chief Raises Warning That Ebola Could Become Airborne

Ebola Could Become Airborne

Ebola in the Air?

Nature: Ebola Mutating Rapidly as it Spreads

Nightmare Chance that Ebola Could Become Airborne, UN Warns

Fort Campbell Troops Headed to Liberia to Fight Ebola

Google/CDC

Media Jumps to Conclusions on Ebola and Climate Change

 

 

 

 

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