San Francisco Chronicle - (Sunday)
China, Italy: Lessons lie with countries stricken earlier, authorities say
The new coronavirus blew up in the Bay Area over the past week: Cases that had once been sporadic suddenly were being reported by the dozens every day. And the region reacted, with dramatic, unprecedented public health tactics designed to slow down the spread of a disease that clearly has a foothold in the community.
Schools are closed, and so are museums and libraries and courthouses and the Chase Center, where the Warriors would be playing if the rest of the NBA season hadn’t been suspended. Employees who can work from home are being told to do so. Everyone is advised to avoid crowds — in some places, including San Mateo County, gatherings of as few as 50 people have been banned outright.
The coronavirus pandemic that has infected roughly 150,000 people worldwide has profound
ly upended Bay Area lives, for at least the next few weeks and potentially for much longer. With hundreds of cases reported in California — but certainly many hundreds if not thousands more that have not been identified due to lack of testing — public health officials across the state are battling a largely invisible epidemic that could overwhelm the health care system and kill countless numbers.
Experts in pandemics say it’s possible that the Bay Area reacted swiftly and strongly enough to prevent disaster, but the true fallout won’t be clear for a while. And in the meantime, the stakes could get still higher in the public health gambit that’s putting economic and social structures on the line to save lives.
“My general sense is that the more cases we see — the more extreme this epidemic becomes — the more likely it is that health departments will start shutting our lives down, bit by bit,” said Eran Bendavid, an infectious disease specialist at Stanford.
And if the current socialdistancing restrictions aren’t working, he said, “I wouldn’t be surprised if we get to Italy.”
The entire country of Italy has been on lockdown for a week, with all nonessential shops and operations closed. American public health experts are watching that country and others carefully now as they try to predict the path of the pandemic in the United States. Italy has more than 21,000 cases and 1,400 deaths. The United States has more than 2,900 cases, but it’s about three weeks behind.
In places through which COVID-19 — the disease caused by the new coronavirus — has already swept, it’s caused varying degrees of chaos. In Italy and in Hubei province in China, the epicenter of the pandemic, hospitals have been crushed by waves of patients needing intensive care. It’s likely that people have died because of the strain on health resources, infectious disease expert say.
The hope is that the United States had enough advance notice of the coming tide to prevent some of the worst fallout through aggressive public health interventions. This past week has seen remarkable moves across the country: Entire states shut down their public schools, the U.S. Capitol closed to the public, and President Trump halted most travel between Europe and the United States.
In a news conference on Friday during which he declared a national emergency, Trump said the next eight weeks would be “critical.” “These short-term sacrifices will produce long-term gains,” he said.
Public health and infectious disease experts are less certain of that.
“This is so rapidly progressing and so aggressive in other countries like Italy and Iran right now, that it’s hard to understand why it won’t behave in a similar manner here. So that portends a bad future for us,” said John Swartzberg, an infectious disease expert at UC Berkeley — where he began teaching his classes online last week, after the campus shut down in-person lectures.
“The positive thing is that China really has bent the curve,” he said. Two and a half months after the first cases were reported there — after a city of 11 million was essentially quarantined — the outbreak appears to have peaked. “Does that tell us that with a lot of public health effort can we make this a three-month or fourth-month disease? Can we be talking about weeks or months as opposed to years? The answer is maybe.”
A major hindrance in the United States has been the lack of testing, which has prevented public health authorities across the country from defining the scope of their community outbreaks. Initially, only people who were most likely to have been infected were tested, and there was no way of knowing if the virus was circulating freely in communities.
Even now that it’s clear the virus is spreading, there still isn’t nearly enough testing available to get a clear picture of how many people are infected and how seriously ill they are.
“We have this big iceberg,” said Shannon Bennett, a virologist and chief of science with the California Academy of Sciences. The base of the iceberg may be people who are infected but have no symptoms — tracking them may not be possible with the current tests, she said. The next group is people who have mild illness, and they’re also not being tracked because they may never interact with the health care system for testing.
Then there are people who are more seriously ill and need to be hospitalized. This group is starting to be identified by testing, but even that remains iffy, depending on the county where they are treated. “And then the tippy top are the deaths,” Bennett said. “You could argue that the most reliable data we’re collecting are the deaths.”
As of Saturday, California had reported five deaths, and there were more than 50 deaths nationwide.
Scientists all over the world are developing models to help countries predict how the pandemic will manifest in their communities, but models are inherently unreliable — and perhaps more so when they’re being crafted in the middle of a global health emergency with data that shift hour to hour. Projections of the number of deaths caused by coronavirus in the U.S. have ranged from the tens of thousands to more than a million if the pandemic is allowed to run unchecked.
“This epidemic is clearly capable of enormous growth,” said Travis Porco, a UCSF biostatistician who does disease modeling. “But you run numbers and you can see this enormous variability, and possibilities through chance. You get enormous predictive uncertainty.
“And you top that off with the fact that we don’t know as much about the infectiousness of this disease,” he said. “Add that up and we’re forced to make difficult decisions with incomplete information, and do the best we can.”
In the Bay Area, counties responded to the first signs of outbreak in late February and have escalated their actions over the past week and a half. Statewide, Gov. Gavin Newsom has called for canceling large gatherings and advised communities to close schools when they deem it necessary.
The next obvious question is: How long will this go on? Bay Area schools are mostly closing for two to three weeks. Indeed, most of the social restrictions put in place so far have a time limit of the end of the month or mid-April. But infectious disease experts said the epidemic in the U.S. and in California is unlikely to be over by then. And public health officials may be talking in weeks because that’s an easier message for the public than “we don’t know,” Swartzberg said.
“If Newsom got up and said we’re going to do all these things and it’s going to be indefinite until it’s safe to stop, people would go nuts,” he said. “I can do anything you want for two or three weeks. But don’t tell me it could be a month, or that you have no idea how long it could be. I can’t deal with that.”
Over the next few weeks, public health officials will be watching coronavirus case counts, for their own counties and for the region, for signs that social distancing tactics are working. They all expect the numbers to climb — perhaps dramatically — over the next week or two as testing becomes more widely available. But they’re hoping to see the dayto-day increases flatten sometime soon.
If the numbers continue to rise seemingly out of control, more aggressive maneuvers may become necessary. That’s when nonessential shops may be closed, along with the handful of schools that remain open for now. Some places that remain open may start doing temperature checks at the doors. Public transit could shut down entirely.
On the other hand, the coronavirus counts could improve. But the life-changing social restrictions are unlikely to let up for some time after that, public health experts said. The lesson from earlier pandemics, said George Rutherford, a UCSF infectious disease expert, is to intervene early and consistently. “You can’t let your foot off the gas,” he said.
In Contra Costa County, Health Officer Daniel Peddycord said the next few weeks will be critical, and that people should expect restrictions to “ratchet up” before they begin to relax. But he added that there are limits to how much public health authorities can do to protect their communities.
The fate of this pandemic, he said, relies largely on the simplest measures: hand-washing, staying home when sick and keeping a distance from others.
“The folks who are in charge now is the community itself,” Peddycord said. “The public is in control of how well we slow down the spread of this disease.”