Testing, Testing, Testing

11 April 2020

Editorial Note: It has been another long week for everyone, me included. I really have two or three Insights worth of material here, and had hoped to get half of this out earlier in the week, and the rest by the weekend. Alas.

Maybe you will find time this weekend to digest this one slowly, over a few sittings. Given where we are at the near peak of the global pandemic, amidst religious holidays and the arrival of the Northern spring, I hope many of you will be able to find some peaceful time with family and friends and loved ones this weekend. We all deserve it.

Today’s Topics:

Recapping the First 100 Days of Covid-19

Testing and More Testing

Updates: China, Treatment, Mobility

Some More PSAs: # 9: Pets and Covid-19 #10: Ventilators and ICUs



It has been 100 days since the Covid-19 coronavirus was identified as a potential pandemic respiratory virus by a medical team in Wuhan, China. It is not hard to lose perspective when things move so quickly, so dramatically, and are so disorienting. And it is worth noting that Wuhan, where this all began, came off lockdown yesterday and is finding its way back toward a version of normal--essentially, Phase 2 of the pandemic.

We’ll cover a few topics today, focused on one that is becoming increasingly relevant as we head globally toward the end of Phase 1, and start to think seriously about Phase 2: testing.

A Brief Recap of Where We Are and How We Got Here, 8 April 2020

(Feel free to skip this section if you feel like you could write it yourself).

Let’s first take a breath, and recap the critical pandemic moments that have taken place in just 100 days, in 12 summary points:

China

1. The Covid19 coronavirus jumped from animals to humans in early December in central China; cases of severe pneumonia of unknown cause were recognized by 30 December 2019.

2. By 20 January 2020: the genetic sequence of the Covid-19 coronavirus was published (officially: SARS-CoV-2); a nasal swab test (RT-PCR) was available; hospitals and ICUs in Wuhan were increasingly overrun with (mostly elderly) patients; and pandemic alerts at WHO and other pandemic preparedness agencies worldwide were triggered. South Korea and the United States each reported their first cases on 20 January.

3. Between 15 and 25 January, Wuhan municipal, Hubei state, and Chinese national authorities implemented increasingly stringent “social distancing non-pharmaceutical interventions,” culminating in a total lockdown of 50 million people and tight restrictions on 1.4 billion more. The longest of these would remain in place some 76 days.

4. The Chinese outbreak plateaued 26 days after the lockdown was implemented, with a 64-fold increase in cases (~6 doubling times), and ~80,000 confirmed cases, including thousands of health workers infected early in the outbreak, and a 3% overall case fatality rate, but 15% in the elderly.

5. China began to loosen restrictions and reboot its economy on 16 March (48 days from lockdown), and released most restrictions in Wuhan on 8 April (76 days from lockdown). Easing of restrictions revealed low-level community transmission, as well as imported cases from inbound travelers--essentially, daily challenges that we will come to know as Phase 2 of the pandemic.

Regional and Global Spread

6. Initially, the Covid19 coronavirus spread quickly to Hong Kong, Singapore, South Korea, and Taiwan in January and early February, and more slowly to the rest of the planet. Many countries identified single cases in inbound travelers in January; then, three pandemic waves crested globally, separated by 10-15 days each. Overly simplified, these were: the first wave, centered in Iran, northern Italy and Spain, and plateauing in late March/early April; the second wave, centered in most of the high-income world (e.g., Europe, U.K., U.S.), expected to plateau in mid-April; and the third wave, centered in most of the low- and middle-income world (e.g., sub-Saharan Africa), expected to plateau in late April/early May.

7. As these waves hit, individual countries/states/territories began to separate themselves by the speed and effectiveness with which they implemented the established playbook for pandemic response: (1) physical distancing interventions; (2) wide testing; (3) patient triage and health worker protection; (4) hospital surge capacity; and (5) clear and consistent public communications, especially around individual accountability, transmission routes, hygiene, and the importance of physical distancing. The pandemic has followed a different trajectory in countries/states/territories that responded proactively (foremost, Hong Kong, Singapore, South Korea, and Taiwan; but also New Zealand, Nigeria, and Ohio, USA, among others), and those that were unprepared, reactive, and/or disjointed in their response.

8. Economic impact has been profound in every country, though mitigated in countries that were pro-active in their response. These latter countries are in, or will soon enter Phase 2, which involves fine-tuning physical distancing interventions and expanding their testing capacity, balancing economic activity against ongoing sparks and embers of transmission.

Exponential Growth and Global Lockdown

9. Some countries caught unprepared for the possibility of a Covid19-like virus have been hit especially hard by exponential growth in cases, high case fatality rates, and overrun health systems--a few like Ecuador, Italy, Spain, and the United States, in overwhelming fashion. As of 1 April 2020, most countries are in the middle of a prolonged 6-10 week period of lockdown--except for those proactive countries already entering Phase 2 of the pandemic.

10. Several models have circulated widely, and are being relied on by policy makers and government officials to project the timelines of the March/April 2020 global lockdown, and to project what Phase 2 looks like with respect to transmission, cases, and hospital capacity. Several models support that countries/territories being able to ease restrictions in May, while other, harder hit countries may need to remain on lockdown into June. The timelines for the last countries to be affected, including most of Africa, remain highly uncertain. And the models differ widely as far as the next global wave of the pandemic, which may or may not come roaring back after lockdowns ease.

11. The balance between transmission mitigation and economic activity that will characterize Phase 2 of the pandemic remains unclear--the models are inconsistent in how they project the impact of easing some of the restrictions now in place, and each country/territory/state will develop their own, highly tailored approach.

12. Drug development and vaccine development is progressing at breakneck speed; there is some hope that effective treatments may become available between September and the end of 2020, while an effective vaccine remains 12-18 months away.

What Does This Mean for April and May?

Most individuals currently under lockdown will need to manage through May. Most countries in the world will need to address an ongoing and massive economic hit to individuals, families, and businesses through May, with timelines depending on the local effectiveness of the implementation of physical distancing interventions. At the same time, policymakers need to be planning for how they manage Phase 2, on a country-by-country, state-by-state, municipality-by-municipality basis.

The key challenge I see here is that the same leadership teams face these three urgent tasks:

Managing the acute Covid-19 patient and hospital crisis, which requires a combination of health system resource procurement, testing logistics, lockdown enforcement, and public messaging; Designing acute fiscal stimulus programs, emergency funds, and bailouts for individual, businesses, and hospitals; and Preparing detailed plans for Phase 2, and how to set thresholds to modulate physical distancing interventions, restrictions on gatherings, school closings, and economic activity.

It seems likely that countries and territories that have managed Phase 1 of the Covid-19 pandemic well through March will continue to manage this next challenge well, while countries that have struggled will continue to struggle. I worry especially for the United States and the United Kingdom as they try to play catch-up on preparedness.

Much of the planning for Phase 2 has already been done, with some variation in China, Singapore, South Korea, and Taiwan since February or early March. Outside of Asia, countries like Austria, Czech Republic, Denmark and New Zealand are expected to relax restrictions before the end of April, and should provide the first data on how well transmission and economic activity can be balanced in these settings, and on which interventions are the most essential.

The Timing of Phase 2

The website Politico has tracked the timing of the interventions in a helpful set of tables, which gives us some idea of how quickly responses were implemented. For instance, the table below for Europe reveals that most countries learned from Italy’s experience to move more quickly toward lockdown, and a few moved especially fast. (Tables for other parts of the world can be seen by following the link below).