Coronavirus COVID-19 Articles

Boston Doctors Speak Out

“As there is so much confusion, misinformation and denial on social media about the coronavirus we hope to explain, in plain language, why the experts see this as such an emergency. Many people are reading the claim online that this virus is a lot like the viruses that cause colds, and that if you get it, it will probably just seem like a bad cold and you are very unlikely to die. Depending on who you are, this may be true, but there is more to this story that is key to our outcome as a community. This is a coronavirus that is new to the human population. Although it is related to the viruses that cause colds, and acts a lot like them in many ways, nobody has ever been exposed to this before, which means nobody has any immunity to it. The virus is now moving explosively through the human population, spreading through respiratory secretions and 10 times more contagious that the flu or cold. Although many people will recover, about 20% will wind up with a serious pneumonia that will require hospitalization. Some will be so ill from the pneumonia that they will die. We estimate this may be 2-3%, but it is higher in Italy’s experience, partially because the healthcare system was overwhelmed so rapidly. In those over age 70, the death rate is 8-20%. 

So if a child catches it on a playdate, they can easily transmit it to their grandmother as easily as touching the same doorknob or countertop. Scientists measure the spread of an epidemic by a number called R0, or “R naught.” That number is calculated this way: for every person who develops the illness, how many other people do they give it to before they are cured (or dead) and no longer infectious? 

The R0 for coronavirus appears to be a number close to 3 – an extremely frightening number for such a deadly disease. Suppose you catch the virus. You will give it to 3 other people, and they will each give it to three others, and so forth. Here is how the math works, where you, the “index case,” are the first line: 

27 

81

243 

729 

2,187 

6,561 

19,683 

59,046 

177,147

 531,441 

1,594,323 

4,782,969 

14,348,907 

So, in just 15 steps of transmission, the virus has gone from just one index case to 14.3 million other people. Those 15 steps might take only a few weeks. With schools closed, maybe less. The first person may be a young and healthy child, but many of those 14 million people will be old and sick, and they will likely die because they got a virus that started in one person’s throat. R0 is not fixed – it can be lowered by control measures. If we can get the number below 1, the epidemic will die out. This is the point of the quarantines and social distancing, but we are not doing it fast enough. In the US, we have to slow down the virus. American hospitals, Boston hospitals, have limited resources. We have a fixed number of ventilators and an impending calamity on our hands. Our Italian critical care colleagues have shared with us that they simply do not have enough resources (ventilators, physicians and nurse, critical care beds), and are forced to choose who lives and dies based on old tenets of wartime triage. Older patients do not even get a ventilator and die of their pneumonia. These are decisions nobody should have to face, and we are only 11 days behind Italy’s fate. Their hospitals are quite advanced, and we are no better in Boston. As doctors, we are desperately trying to prepare for the onslaught of patients in the coming weeks. It is already beginning. This is an opportunity for you as the district leadership the time to be aggressive and help us fight this by “Flattening the Curve”. We implore you, as a group of Boston’s doctors preparing to fight this, to help us. Please send a new email to ALL. Social distancing is painful. We know that kids have cabin fever, they are pleading to see their friends, they may have birthday parties coming up or special events they have been looking forward to. All of us need to work and childcare is a big worry. But we need to overcome these issues and boredom for the coming weeks so that we can survive this with as few deaths as possible. What does that mean? 1) No playdates, not even 1:1. 2) No small gatherings, no meetings between a couple families, even for birthday parties. 3) Avoid trampoline parks, climbing gyms, restaurants, movie theaters, anything in an enclosed area. Many of these places are advertising increased cleaning and hygiene. This is not sufficient! Do not go. 4) Cancel planned vacations for the next month. Avoid airline travel that is not an emergency. Many airlines and rental agencies are offering penalty free cancellations. 5) Stay at home as much as possible. Work from home if you possibly can. You may have to go buy groceries and medicine, of course, but make the trips quick and purposeful. 6) Wash your hands thoroughly after you have been in public places, for a full 20 seconds, soaping up thoroughly and being sure to get between the fingers. 7) Please avoid disseminating social media claims that the situation is not serious or is being exaggerated. This is a national crisis and conveying misinformation to your friends and family may put their lives in danger. Thank you for taking the time to read this and stay safe and healthy in the coming weeks.” 

Respectfully, Erika Rangel, MD, Director of Surgical Critical Care, Brigham and Women’s Faulkner Hospital Shawn Rangel, MD, Pediatric Surgery, Children’s Hospital Boston Asaf Bitton, MD, Executive Director Ariadne Labs and Internal Medicine, BWH Daniel O’connor, MD, Pediatrics, Longwood Pediatrics and Children’s Hospital Boston Beth O’connor, MD, Pediatrics, Roslindale Pediatrics Vandana Madhavan, MD, Clinical Director of Pediatric Infectious Disease, MGH Parag Amin, MD, Pediatrics, Centre Pediatrics Christy Cummings, MD, Neonatology, Children’s Hospital Boston Eric Bluman, MD, Orthopedic Surgery, BWH Trimble Augur, MD, Internal Medicine, Hebrew Rehabilitation Center Dasha Weir, MD, Pediatric gastroenterology Amy Evenson Warren, Transplant Surgery, BIDMC William Oldham, MD, PhD, Pulmonary and Critical Care Medicine, BWH James Kryzanski, MD, Neurosurgery, Tufts Medical Center Ben Zendejas-Mummert, MD, Pediatric Surgery, Children’s Hospital Boston Johanna Iturrino Moreda, MD, Gastroenterology, BIDMC David Berg, MD, Cardiology and Cardiac Critical Care, BWH Jennifer Crombie, MD, Hematology Oncology, BWH Jenifer Lightdale, MD, Chief of Pediatric Gastroenterology, U Mass Memorial Hospital Wayne Tworetzky, MD, Pediatric Cardiology, Children’s Hospital Boston Elaine Yu, MD, Endocrinology Jonathan Li, Infectious Disease Nancy Cho, MD, Surgical Oncology, BWH Eric Sheu, MD, Minimally Invasive Surgery, BWH Reza Askari, MD, Director, Surgical Critical Care, BWH Cindy Lien, MD, Internal Medicine and Palliative Care, BIDMC Hannah Parker, MD, OB/GYN Alysa E. Doyle, PhD, Center for Genomic Medicine, MGH Christopher Smith, MD, Internal Medicine, Charles River Medical Associates, Wellesley, MA Maya Greer, NP, Children’s Hospital Boston Rusty Jennings, MD, Pediatric Surgery, Children’s Hospital Boston Emily Oken, MD, Professor of Population Medicine, BWH Chinwe Ukomadu, MD, Head of Clinical Hepatology, Novartis Jennifer Kaufman, MD, Internal Medicine, BWH Ann Poduri, MD, MPH, Pediatric Neurology Susan Yehle Ritter, MD, Rheumatology Diego Martinucci, MD Psychiatry, Atrius Health Shih-Ning Liaw, MD, Pediatric Palliative Care, Dana-Farber Cancer Institute/Boston Children’s Hospital Wolfram Goessling, MD, Gastroenterology and Oncology, MGH Paola Daza, Pediatrics, MGH Juan Matute, Neonatology, MGH John Ross, MD, Internal Medicine, BWH Megan Sandel, MD, Pediatrics, Boston Medical Center Kathy Calvillo, MD, Surgery, BWH Christine Greco, MD, Anesthesia, Children’s Hospital Boston Niteesh Choudhry, MD, PhD, Internal Medicine, BWH and Harvard T.H. Chand School of Public Health Chandru Krishnan, MD, Ophthalmology, Tufts Medical Center Amy Ship, MD, Internal Medicine, Associate Director of Medical Education, Atrius Health Yen-Lin Evelyn Chen, MD, Radiation Oncology, MGH Daihung Do, MD, Dermatology, BIDMC Chloe Zera, MD, MPH, Maternal Fetal Medicine, BIDMC Alejandra Barrero-Castillero, MD, MPH, Neonatology, Children’s Hospital Boston Jesse Esch, MD, Pediatric Cardiology, Children’s Hospital Boston Alison Packard, MD, OB/GYN, MGH Vik Khurana, MD PhD, Chief Division of Movement Disorders, BWH Tu-Mai Tran, MD, MSc, Family Medicine, BMC Yu Liu, MD PhD, Internal Medicine, Bristol Myers Squibb Yih-Chieh Chen, MD Lily Li, MD, Allergy and Immunology, BWH

Epidemiologist describes spread of corona virus

BY JONATHAN SMITH

Hey everybody, as an infectious disease epidemiologist (although a lowly one), at this point feel morally obligated to provide some information on what we are seeing from a transmission dynamic perspective and how they apply to the social distancing measures. Like any good scientist I have noticed two things that are either not articulated or not present in the “literature” of social media. I am also tagging my much smarter infectious disease epidemiologist friends for peer review of this post. Please correct me if I am wrong (seriously). Specifically, I want to make two aspects of these measures very clear and unambiguous. First, we are in the very infancy of this epidemic’s trajectory. That means even with these measures we will see cases and deaths continue to rise globally, nationally, and in our own communities in the coming weeks. Our hospitals will be overwhelmed, and people will die that didn’t have to. This may lead some people to think that the social distancing measures are not working. They are. They may feel futile. They aren’t. You will feel discouraged. You should. This is normal in chaos. This enemy that we are facing is very good at what it does; we are not failing. We need everyone to hold the line as the epidemic inevitably gets worse. 

This is not my opinion; this is the unforgiving math of epidemics for which I and my colleagues have dedicated our lives to understanding with great nuance, and this disease is no exception. We know what will happen; I want to help the community brace for this impact. Stay strong and with solidarity knowing with absolute certainty that what you are doing is saving lives, even as people begin getting sick and dying around you. 

You may feel like giving in. Don’t. 

Second, although social distancing measures have been (at least temporarily) well-received, there is an obvious-but-overlooked phenomenon when considering groups (i.e. families) in transmission dynamics. While social distancing decreases contact with members of society, it of course increases your contacts with group (i.e. family) members. This small and obvious fact has surprisingly profound implications on disease transmission dynamics. Study after study demonstrates that even if there is only a little bit of connection between groups (i.e. social dinners, playdates/playgrounds, etc.), the epidemic trajectory isn’t much different than if there was no measure in place. 

The same underlying fundamentals of disease transmission apply, and the result is that the community is left with all of the social and economic disruption but very little public health benefit. You should perceive your entire family to function as a single individual unit; if one person puts themselves at risk, everyone in the unit is at risk. Seemingly small social chains get large and complex with alarming speed. If your son visits his girlfriend, and you later sneak over for coffee with a neighbor, your neighbor is now connected to the infected office worker that your son’s girlfriend’s mother shook hands with. This sounds silly, it’s not. This is not a joke or a hypothetical. We as epidemiologists see it borne out in the data time and time again and no one listens. Conversely, any break in that chain breaks disease transmission along that chain. In contrast to hand-washing and other personal measures, social distancing measures are not about individuals, they are about societies working in unison. These measures also take a long time to see the results. It is hard (even for me) to conceptualize how ‘one quick little get together’ can undermine the entire framework of a public health intervention, but it does. I promise you it does. I promise. I promise. I promise. You can’t cheat it. People are already itching to cheat on the social distancing precautions just a “little”- a playdate, a haircut, or picking up a needless item at the store, etc. From a transmission dynamics standpoint, this very quickly recreates a highly connected social network that undermines all of the work the community has done so far. Until we get a viable vaccine this unprecedented outbreak will not be overcome in grand, sweeping gesture, rather only by the collection of individual choices our community makes in the coming months. This virus is unforgiving to unwise choices. My goal in writing this is to prevent communities from getting ‘sucker-punched’ by what the epidemiological community knows will happen in the coming weeks. It will be easy to be drawn to the idea that what we are doing isn’t working and become paralyzed by fear, or to ‘cheat’ a little bit in the coming weeks. By knowing what to expect, and knowing the importance of maintaining these measures, my hope is to encourage continued community spirit, strategizing, and action to persevere in this time of uncertainty.