SECOND WAVE? What to expect over the summer and fall

 

We’re now in mid-May and have been under some form of social distancing and/or “stay at home” orders for over two months. The virus has played havoc on the economy and our elected leaders are wrestling with the best way to open society back up while minimizing the associated risk. First among those risks is the possibility of a second wave of the epidemic. The one thing no one wants is to start opening businesses, schools, sporting events and other activities just to go through a second round of closing everything back down again. It would seem that the nation’s political leaders and infectious disease experts would be of a like mind on this topic. A significant second wave of COVID-19 in the fall would be a disaster for both politicians coming up for re-election in November and the medical community. That’s why the stark differences in the messages coming out of the White House and the medical community is so surprising. In this article I’ll examine the competing predictions and look at the evidence to try and get at the truth concerning what we can expect from the Coronavirus between now and November.

I’ve been critical of Trump’s lack of consistency on the COVID-19 crisis, but when it comes to a second wave of the virus he has presented a consistent message. In late April the President stated, “if it does come back, it’s in a very small, confined area that we put out.” Like most of Trump’s non-scripted comments it can be a challenge to make sense of his broken English, but his message was that there might be a few confined clusters of cases in the fall, but they will be quickly isolated to prevent another outbreak. He went on to repeatedly stress that, “we will not go through what we went through for the last two months,” adding that, “it is estimated it might not come back at all.” In the three weeks since these statements he’s remained uncharacteristically on message that the worst of the virus is over and that he’s put in place the measures needed to contain any outbreaks that pop up later on. Just this week Trump stated, “I think we have to open our schools . . . we have to get it open, I totally disagree with him on schools.” The “him” Trump referred to was Dr. Anthony Fauci who is not willing to recommend reopening schools at this point, in part due to a newly recognized syndrome that is causing severe symptoms in school aged children with the Coronavirus.

So, Trump wants everyone to know he has handled the situation, and this will all be over soon. However, this is not the position of his own infectious disease experts. The Director of the CDC, Dr. Robert Redfield recently told the Washington Post, “There’s a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through.” Trump’s response to the quote was to say the doctor had been, “totally misquoted by fake news,” forcing Dr. Redfield to publicly confirm the quote was accurate. Part of the point Dr. Redfield was making is a second wave in the fall will likely coincide with the normal flu season which would compound the problem and lead to confusion since some of the symptoms overlap between the two viruses. Dr. Gregory Poland of the Mayo Clinic echoed this point saying, “I think among those of us who study (infectious diseases), we believe a second wave will be an inevitability.” He went on to say, “The increased danger is influenza and COVID-19 would overlap in timing . . . you have a double whammy because many won’t know what’s going on. Is it the flu? Is it COVID-19? Is it both?” Dr. Shoshana Ungerleider of Sutter Health predicted that a second wave is, “very, very likely to happen . . . this may put a heavy strain on an already taxed healthcare system, so I think we need to be preparing for this now.” Finally, Dr. Rick Bright, the former director of the Biomedical Advanced Research and Development Authority testified before Congress on May 14th that, “There will be likely a resurgence of COVID-19 this fall. It will be greatly compounded by the challenges of seasonal influenza. Without better planning, 2020 could be the darkest winter in modern history.” Rather than being praised by the Trump administration for being an early proponent of taking action to limit the impact of the epidemic, Dr. Bright was removed from his position for being critical of the administration’s unwillingness to take action and for promoting the use of unproven remedies for the virus.

Dr. Michael Mina of the Harvard School of Public Health explains why the second wave is both likely to happen and be worse than the first wave. “Once we start opening things back up, we’re going to have a lot of individual cases that are still brewing under the surface . . . if we don’t put out all the flames, then we’ll have this smoldering number of people that will all be able to ignite outbreaks at once,” said Dr. Mina. The initial outbreak was largely limited to a few cities with large numbers of international travelers like Seattle, San Francisco, and New York. In the fall there will be underlying cases in all 50 states so when the conditions for an outbreak become more favorable it’s likely to be everywhere all at once. It’s probably impossible to completely stamp out all the flames of this virus over the summer, but the reopening of businesses when we’re still near the peak of the first wave makes a more severe second wave a near certainty. For the second wave we should have the advantage, at least in theory, of being better prepared. However, when the President is denying there will be a second wave contrary to all the evidence it’s hard to have much faith that will be the case.

These warnings from the medical experts aren’t just theoretical, there’s historical precedent. Immunologist Mark Cameron worked on the SARS Coronavirus back in 2003 in Toronto which had a severe outbreak of the virus. After a two-month declaration of emergency they reopened for business as usual and invited visitors back to the city. Within two weeks the virus came back as bad as the first wave. Dr. Cameron expressed a concern the same thing could here, and the second wave could hit even before the fall, and like Dr. Mina’s warning, he predicts the second wave will be much more widespread than the first. The SARS pandemic wasn’t alone in this outcome. The H1N1 pandemic of 2009 saw 4.6 times more deaths in the second wave than in the first. Similar results for COVID-19 would result in huge numbers of deaths. Probably the most concerning example of a second wave of a pandemic is the 1918 Spanish Flu outbreak. Like the Coronavirus, the Spanish Flu epidemic broke out and took a huge toll in the spring and early summer, but by August it seemed to have run its course. However, over the course of the next three months approximately 500,000 Americans died in the second wave of the virus. When you adjust for today’s increased population that would be the equivalent to about 800,000 deaths today. These examples show the risk in not taking seriously the chances of a second wave occurring sometime later this year. Trump seems to be banking on a vaccine and other miracle treatments being ready by the fall but so far they’ve been elusive. The likelihood they’ll be both ready and widely available by September or October seems remote at this point.

So, what can be done? Is there even any evidence that social distancing works or are we simply at the mercy of the virus. Thanks to Google we actually have some data to look at to give us some answers to that question. Nearly everyone carries a GPS tracker around with them everywhere they go in their smartphones. Google is releasing anonymized data on people’s movements to gage the degree of real-world social distancing in locations around the world. This is giving us real data concerning the types of places people are going and with what frequency. The first set of data I looked at was a comparison of the frequency of travel to retail and entertainment establishments in Oregon and Oklahoma. I choose these two states because they are similar in many ways but took differing approaches to the current pandemic. They are approximately the same size, both in area and population, they both have sizable urban and rural areas, and have somewhat similar demographics, however Oregon took more aggressive social distancing measures than Oklahoma. The company Unacast gave each state a grade for their Coronavirus response, Oregon received an above average score while Oklahoma was near the bottom of the list. The below chart shows that both states began social distancing at the same time but the number of Oregonians that have avoided retail outlets is considerably higher. Beyond that, the number of people going to retail outlets began moving back up sooner and more sharply in Oklahoma than in Oregon. By the 7th of May Oklahoma was only 8% below normal while Oregon was still down by 31%. When we look at the rate of COVID-19 deaths we find Oklahoma has a much higher rate. At the beginning of April the two states had nearly identical rates of deaths, but soon after we see a marked increase in the number of deaths in Oklahoma. By May 12th they had a rate of COVID-19 deaths 234% of Oregon’s with the margin continuing to grow wider. Of course, there could also be other unknown factors contributing to these results, but this is a dramatic difference.

Perhaps an even better comparison comes from Europe. The Scandinavian countries of Norway and Sweden share a border over a thousand miles long and are demographically and culturally quite similar, but took drastically different approaches to dealing with the Coronavirus. Sweden decided to make social distance recommendations but mostly made the measures voluntary, Norway on the other hand implemented very aggressive stay at home rules. The chart below shows that Norway took action about a week earlier, but more significantly reduced their social interactions much more drastically than Sweden. Norway and Sweden started April with nearly identical rates of death, however by May 12th Sweden’s was nearly eight times higher. You can see that because Norway took quick and decisive action they were able to ease up on the social distancing sooner than in America while maintaining a nearly flat number of fatalities. The key to their keeping the rate of deaths low even after removing the stay-at-home rules is they didn’t go back to life as usual. They continue to mandate strict measures to limit the spread of the disease even as they allow greater freedom of movement and limited retail commerce. I’ve seen some right-wing memes on Facebook point to Sweden as the model for how America should handle the Coronavirus pandemic. Even a cursory examination of the facts shows Sweden’s response was disastrous. Norway seems to have discovered the secret sauce for safely reopening their economy.

It’s clear that the key to limiting the size and severity of a second wave is to maintain strict social distancing until new cases of the virus are down dramatically followed by continued measures to limit the spread even as limited reopening of the economy takes place. This needs to happen at the same time greatly expanded testing is made available to identify and isolate people who have been exposed to the virus. Even these actions are unlikely to completely avoid a second wave, but they could greatly reduce it and ultimately lead to a quicker economic recovery. President Trump’s own Guidelines for Opening Up America Again gives very similar advice, this isn’t a secret. Despite this Trump has shown remarkably little willingness to follow his own administration’s guidance and many state governments around the country (particularly states with Republican controlled governments) are throwing caution to the wind and only paying lip to continued social distancing. I would think in an election year enlightened self-interest would encourage politicians of both parties to want to avoid a second wave of the virus right before the election. However, the Republican party under President Trump’s leadership continues to be unable to think past the next 24-hour news cycle. A deficiency that the country and likely the Republican party will pay for next fall.