6/8/2020 It is time to move faster towards normalcy

Recently, our attention may have been diverted from the daily pandemic headlines and COVID case counts to news of protests and social unrest. Many in the media and epidemiologists have expressed concern that we will encounter a spike in COVID cases, hospitalizations and possibly deaths due to the breech in social distancing protocols. We should know within a week or two. It will be more important to watch the number of deaths and hospital admissions due to COVID as opposed to the number of new cases since this later measure reflects more testing capacity.  I suspect that there will not be a significant increase in the number of COVID deaths in the coming weeks.   

Why do I think that we can change Oregon’s current approach and generally resume normal activities? First, there is evidence that the pandemic likely started in the U.S. earlier than has been recognized by public health officials.  Second, there is evidence that many people are not susceptible to the virus for undefined reasons.  There may be more innate immunity in the population than has been understood previously. This would represent another factor besides lockdown that prevents the spread of the virus. Third, the virus isn’t nearly as lethal as first advertised which has been demonstrated by the delayed public reporting of the consistently falling infection lethality rate.  The initial models that were followed by most governments including our own, assumed the “worst case scenario”.  Remember the infection fatality rates falling from 3.4% to 1% to 0.4% and now as estimated by Dr. Gupta and others, to be 0.05 to 0.1%.  This COVID infection lethality range was proposed by Dr. John Ioannidis based upon the Diamond Princess Cruise line data. I previously presented his opinion in the 3/17/20 publication of STAT and other interviews. Fourth, other U.S. states and countries have relaxed their COVID restrictions and have not seen a significant rate of increase in the number of COVID deaths that many experts predicted.  In fact, the COVID death rate is clearly decreasing despite a relaxation of lockdown policies. In my view, we have enough data now to rethink Oregon’s very slow and deliberate phased reopening plan.

Additionally, there are valid arguments that the U.S. lockdown policy will have little impact on the ultimate outcome of this pandemic except for the timeline of the viral progression through the population.  We hope that the U.S. can establish enough immunity in our country in order to protect our most vulnerable and reduce the viral transmission at later dates. This statement is supported by comparing how the pandemic has progressed through different countries with varied public health and testing policies. The arguments for more restrictive approaches during this pandemic would be for COVID-19 hotspots where medical resources were overwhelmed – like New York City.   Following standard precautions to wash hands, increase care capacity, protect the elderly and those with comorbid conditions may have resulted in similar outcomes and less overall harm.  A more measured, targeted approach would have been less likely to result in the adverse consequences to other medical conditions, education, and other social determinants of health. We also may not have had as severe of an economic catastrophe due to the lockdown itself.

My blogs on Evergreen’s website and social media were meant to introduce Evergreen patients, providers, policy makers and my community to interviews with various experts in the fields of infectious disease, biostatistics and epidemiology from around the globe.  The interviews really represent an outstanding opportunity to hear unfiltered opinions from physicians and research experts by an interviewer without a political agenda. I have found the discussions to be generally more enlightening than official public communications. In my view, the delay in sharing and publishing medical research about new COVID-19 information has adversely impacted timely decision-making in this pandemic. Policy makers may have found themselves presented with confined expert viewpoints.  In this type of environment, policy decisions may become susceptible to an echo chamber that leads to a doubling down of policy that is not supported by the best available data.   Such a scenario has the potential to magnify mistakes.  

There are differing opinions from experts about how to proceed from this point forward.  My viewpoint is based upon clinical experience, global pandemic research, timely expressed expert opinion, CDC data and an observational Evergreen Urgent Care antibody study.  Below, there are two interview links to opposing academic perspectives from Drs. Gupta and Dean.  I think the data supports Dr. Gupta and Dr. Ioannidis’ perspective on infection lethality rates and the dangers of overreacting during this pandemic. Lockdown TV by “UnHerd” has done an excellent job with many interviews from experts around the globe about this pandemic.  It is important to hear different perspectives of the available data if we are to embrace a scientific process. For this reason, I have included Dr. Dean’s interview who holds a contrary opinion to mine but one that would likely be considered a standard public health endorsed position.  

We may need lockdown and quarantine measures again someday.  This is especially true if a more lethal, novel virus appears in the future that impacts the young and has an infection lethality rate of 30% like the world experienced with the smallpox virus.  However, this is not the case with COVID-19.  My concern is that if we don’t change approaches in a timelier fashion, public health officials will risk losing credibility with Oregonians.  The data is providing evidence that draconian measures are no longer required and likely are increasing the total harm to our communities.  We cannot wait a year or more for a vaccine in order to resume normalcy since there is no guarantee that these efforts will be met with success.  We can take comfort that the data provides evidence that the infection lethality rates continue to fall and that those who are under 65 and healthy can reengage normally in society.

Respectfully,

John Powell M.D.

Sunetra Gupta, PhD, professor of theoretical epidemiology at Oxford University.

She discusses Oxford University’s early modeling of the pandemic and her argument against continuing the lockdown. Although I am not endorsing her implied political statements, she does make an interesting inference that the measures taken to date may have created similar conditions to the influenza pandemic of 1918-19 that primed the population for a more severe second wave.

Natalie Dean, PhD, assistant professor of infectious disease biostatistics at University of Florida

She makes the case for continued lockdowns, testing and contact tracing.  She considers policies that promote community (herd) immunity to be irresponsible. Although I disagree with her perspective, the approach certainly needs to be considered and is a common public health approach by most states.

Addendum: Infection lethality rate for SARS-CoV-2 is an important determination as we consider our path forward to normalcy. Far from the infection lethality rate of 3.4% predicted by the WHO back February, or the 1% used by the Imperial Model (implying a pandemic global death toll of 40 million people), serological studies done so far suggest average IFR of about 0.2%. The lethality rate is likely less than 0.2% because antibody detection has been observed to underestimate the number of COVID exposures. In Newport, Oregon, we recently had an outbreak at a seafood plant with 124 testing positive by PCR and 95% of the people were reported to be asymptomatic. As of 6/15/202, Johns Hopkins reports 434,388 global deaths related to COVID-19.  The CDC has estimated that up to 646,000 people die yearly from influenza worldwide.  This influenza estimate was calculated by using at least 4 years of data for each country between 1999-2015 but excluded the deaths during pandemics.

Here are some recent examples of serology data suggesting a lower COVID infection fatality rates than suggested previously by public health authorities:

John Powell M.D.

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