How long will this last? Be ready for months of coronavirus restrictions - AL.com

The return to normal is not just around the corner.

“I have a bad feeling that this is going to be lingering with us for at least three months,” said UAB’s Dr. Michael Saag, an infectious disease expert who recently announced that he tested positive for the coronavirus.

Alabama State Health Officer Dr. Scott Harris said Tuesday that three to four months was “a reasonable place to start guessing,” how long the disease might last.

Alabamians hunkered down in self-quarantined home offices that also have to function as daycares, without even the options of escaping for a meal or a spring football game, are surely hoping for a fast return to their pre-coronavirus lives.

They’re the lucky ones. An estimated 66,000 people in Jefferson County alone could lose income due to business shutdowns aimed to slow the spread of the virus, not to mention those COVID-19 patients who will not live to see a return to normal. Mobile has also shut down its restaurants and bars.

Barring a miracle, Alabama hasn’t seen the worst yet, not by a longshot.

The virus is being spread in the Birmingham metro area and case numbers are rising in other parts of the state as more people are able to get tested. The state can reasonably expect case numbers to double every day or two, according to Dr. Jeanne Marrazzo at UAB.

On Monday, the White House released a series of guidelines to limit social contact and reduce spread of the coronavirus titled “15 days to slow the spread,” but in all likelihood governments in Alabama and abroad will have to decide how long they can continue these efforts to limit the disease, because we won’t be out of the woods by then.

“Two to three weeks may not be long enough to have the needed effect,” said Dr. Turner Overton, an associate professor in UAB’s Division of Infectious Diseases. “This situation is evolving rapidly and we need to respond as we gain more information and have more testing available.

“We need to prepare to work as a society to understand that our individual and societal health may require physical distancing for an extended period.

“We need to maintain our social contacts through other methods than congregating in social groups, be that at restaurants, bars or churches. Our vigilance to this approach as a society may help shorten the period of time that these measures are required.”

Without mitigation, model predicts 2.2 million American deaths

While those social distancing and other practices can help, the virus presents a monumental challenge to the American healthcare system.

“We’re going to have a shortage of healthcare providers,” Saag said. “Sorry, that’s just the way it’s going to be. And as the epidemic explodes a little bit more, that’s going to be even more pressing.

“We’re not quite there yet. I don’t think we’ve reached a critical mass of cases.”

When that crunch hits and how bad it is, is still a matter of speculation.

A group of British doctors at Imperial College, one of the most respected academic universities in Britain, used computer models to simulate how different strategies like social distancing and school closures might impact the spread of the coronavirus in the United States and the United Kingdom.

The results were startling. Without any mitigation measures (a scenario the authors say is unlikely), the Imperial computer model projected that 81 percent of the population of the U.S. and U.K. would become infected with coronavirus, leading to an estimated 510,000 deaths in Britain and 2.2 million COVID-19 deaths in the United States, and that’s without accounting for “the potential negative effects of health systems being overwhelmed on mortality.”

Under a more likely mitigation scenario, the report estimated that 1.2 million Americans could still die. The report was prepared for the U.K.’s COVID-19 response team last week and was shared with the White House on Sunday. The report helped jar the British and American governments to accelerate their precautions like social distancing, according to The New York Times,

Some experts have disagreed with the predictions, saying the model was based on incomplete data from China.

But no one is saying this ends quickly.

“I think this idea … that if you close schools and shut restaurants for a couple of weeks, you solve the problem and get back to normal life — that’s not what’s going to happen,” Adam Kucharski, an epidemiologist at the London School of Hygiene and Tropical Medicine told Vox.com in a recent story. “The main message that isn’t getting across to a lot of people is just how long we might be in this for.”

President Donald Trump issued his new guidelines on Monday and states, including Alabama, began stepping up their COVID mitigation plans.

The question now is how effective those strategies will be and how long we can keep them up. As the authors of the report note, the social and economic costs of prevention measure are substantial and unprecedented.

Are we Italy or South Korea?

When trying to predict the course of this disease, scientists have looked at South Korea and Italy. Given those choices, we do not want to be Italy.

Italy has already recorded 31,506 total cases of coronavirus and 2,501 deaths, according to the March 18 situation report from the World Health Organization.

That means 7.9 percent of people who were diagnosed with coronavirus in Italy have died already. That does not include those who have tested positive but may still succumb to the illness, or those who died of something else because Italian hospitals became overwhelmed, or those who died but were not tested for coronavirus and may have had it. The tally also doesn't include asymptomatic people who were never tested.

South Korea, by contrast has reported 8,320 cases of coronavirus and seen 81 deaths. That’s about a 0.97 percent mortality rate so far, though the same caveats apply.

So why the difference?

Dr. William Curry, associate dean of rural medicine at UAB, said the country’s responses to the pandemic have a lot to do with the overall impacts to the two countries. Italy’s healthcare system was overrun, while South Korea was able to implement coronavirus testing on a massive scale to keep the initial outbreak contained, though other clusters are now emerging in that country.

South Korea’s widespread testing and isolating exposed patients seems to have effectively “flattened the curve” and limited mortality. Six days ago, South Korea reported more coronavirus recoveries than new cases. The country may soon restart its professional basketball league. Italy is a different story.

“In Italy, there was a sudden onrush of a large spike of patients in a short period of time needing healthcare,” Curry said. “It overwhelmed their health care facilities, equipment, and staff. And so they have people backed up in hallways and people not able to get into health care facilities that literally are going and lacking treatment and quite possibly having deaths that could have been avoided if that could have been spread out.

“The other scenario is more like what happened in South Korea. So that even if you have the same number of people, instead of the big peak like this, you have a flattened peak that’s going over a long period of time.”

Worldwide, there are now more than 191,000 confirmed cases and 7,800 deaths.

Flying blind right now

Dr. Karen Landers with the Alabama Department of Public Health said the department would “closely monitor and make recommendations based upon numbers of cases and transmission,” about when to end restrictions on things like eating in restaurants.

But the lack of testing capability is hurting doctors’ ability to know how bad the spread already is in Alabama, according to Overton.

“Without adequate testing, we are blind to the actual epidemiology,” Overton said.

Once we fix that blind spot, Overton said, we’ll have a better idea of when we should begin easing these restrictions, but it could be a while before returning to pre-COVID life.

“Once this testing is available, we need to see the proportion of persons testing positive for the virus to be at or near zero,” he said.

That may not happen until the development of a vaccine, which would likely be 12-18 months away, or the development of a “herd immunity,” in which enough people develop resistance to the virus to slow the spread. Herd immunity is not assured, though. We don’t even know if getting the virus once will prevent a person from getting it again after they’ve recovered.

“We should not take a ‘wait-and-see’ approach to this virus while a large proportion of the population develop immunity,” Overton said. “That would be a cavalier approach that is not warranted. We do not even know if persons would be protected from reinfection.”

Short-term measures can help

Even if it might not get you back into Applebee’s next week, measures like social distancing, closing restaurants and schools and limiting large gatherings can reduce the spread of coronavirus, Overton said.

“An aggressive period of social distancing can have a major impact on transmission,” Overton said. “Particularly for this virus that is spread from person to person with a proportion of the transmission happening due to asymptomatic individuals.

“These simple measures can have a profound effect, particularly in the setting where limited testing is available, like much of the United States.”

Even in South Korea, however, the suppression efforts leave the company vulnerable to new outbreaks of the disease. The Imperial College report suggests that measures like social distancing could still be effective in waves, if there is enough testing to alert epidemiologists when and where the resurges.

“We show that intermittent social distancing – triggered by trends in disease surveillance – may allow interventions to be relaxed temporarily in relative short time windows, but measures will need to be reintroduced if or when case numbers rebound,” the authors state.

A trio of doctors from the University of Pennsylvania wrote to The New York Times that people should “plan for social distancing at least until mid- or late May, and be thankful if it eases off earlier.”

Even then, they say, the social distancing and other precautions will likely need to be reinstated as the virus pops up again, leading to waves of closures and calls for distancing. After all, the point of social distancing is to flatten the curve, slow the disease down and prevent hospitals from being overwhelmed. That means we’ll also be dealing with the disease longer.

“Maybe the best analogy is pumping a car’s brakes on an icy road,” the doctors wrote. “Either doing nothing or slamming on the brakes leads to an accident. So we pump the brakes — pushing on the brakes, then easing up, and then applying them again — and after three or four times we slow down enough to stop.”

That means it’s up to us to avoid the worst-case scenarios described in the report and to be aware that there is no short-term fix for this problem.

“We need people to do their part,” Curry said. “This is something we’re all in. We’ve never seen anything like this before in our country, so we’re asking people to engage in what really is a battle.

“We have to do this together if it’s going to work.”

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