Alternative strategies to combat COVID-19 from a public health perspective

Gary B. Ewing, MD, MPH. Board certified in Public Health.

March 22, 2020

Dichotomous Attack on COVID-19 – Steepen and Flatten the Curve Concurrently

﻿Abstract

The flatten the curve approach applied to the entire population using isolation as a response to COVID-19 is inadequate by itself. It is crippling economies throughout the world and, in many countries, not accomplishing the goal of slowing the spread of the infection enough to avoid overwhelming our health care systems. We need a dichotomous strategy in response to COVID-19 which will continue to flatten the curve for older high risk and comorbid individuals, while concurrently steepening the curve for younger healthy and risk factor free individuals. There are two strategies that could steepen the curve for the younger and risk factor free cohort. First is The Volunteer Inoculation Strategy. This strategy would involve using carefully screened volunteers who would be infected with COVID-19 under medical supervision and then quarantined until deemed no longer contagious. The screening process for the volunteers would need to be stringent and only those with a low risk of mortality would be allowed to participate. The second dichotomous strategy is The Low Risk Naturally Acquired Immunity Strategy. This strategy would allow everyone under age 40 to 50 who are risk factor free to continue to work and function in society as they normally do. No quarantine or isolation precautions would be employed for this group. Conversely, those deemed to be at risk from COVID-19 would be simultaneously and voluntarily quarantined with care and aid provided to them until it was safe for them to be released from quarantine. As a result of either dichotomous strategy, we would create a subpopulation immune to the virus who would be able to walk freely about their communities. These immune individuals could return to work and a normal way of life without fear of continuing to spread the virus. They would also serve as caregivers to the rest of the world who are infirmed or not yet immune, and would be able to reintroduce themselves into the lives of family and friends who are vulnerable and quarantined. Current evidence from a study by ISS Italy National Health Institute, March 17, 2020, demonstrated a zero percent death rate in those under age 50 without a serious existing medical condition. It is crucial that we acknowledge the vastly different effect of COVID-19 based on one’s age and comorbidity, and treat these groups differently in response. We need time in order for physicians and scientists to develop antiviral medications and vaccines for COVID-19. A dichotomous strategy to concurrently flatten the curve and steepen the curve for the appropriate individuals could give us that time without crippling our economy and health care system.

The Flatten the Curve Approach:

The current strategy the United States, and the world at large, has taken to contain the novel Coronavirus (COVID-19) from widespread infection is to “flatten the curve” of disease transmission to the entire population. That is, use isolation measures to attempt to forestall infection of all ages in the early days and weeks of the virus’ introduction to a population. The reasoning behind this strategy is not so much to prevent the number of those that will become infected but, rather, to spread out the infections over the course of the viral contagion period.

The goal of spreading the infections over time is twofold. First, to avoid overwhelming our health care system. Hospitals and staff are in limited supply along with beds and ventilators which are needed to adequately treat those with critical infections. If hordes of acutely ill patients descended upon health care systems in the early stages of viral outbreak, demand will exceed supply of these resources. There will likely be resultant deaths that could have been otherwise prevented.

Secondly, spreading out of infections might also allow time for effective antiviral medications and/or vaccines (AV/Vac) to be developed and provided so that some never become infected at all, or have effective treatments if they do. Currently, it is believed it may be at least 12-18 months or longer before wide distribution of a vaccine is available to the public. But, according to Benjamin Neuman, a virologist at Texas A&M University-Texarkana, “immunizing against the pathogen is a long shot: There has never been a very successful human vaccine against any member of the coronavirus family [of viruses].” At this point we simply do not know how long we are going to have to wait for an effective vaccine.

The problems caused by the Flatten the Curve Approach:

Flatten the curve strategy has wrought, to every nation’s economy, terrible consequences that rivals and exceeds many wars and terrorist attacks. The requirement of isolation and quarantine has even the largest of businesses failing. In some places the elderly and even entire populations have been quarantined. Possibly worse is the climate of fear that has been created. People of all ages have been shown to hovel in their homes awaiting this unseen monster to pass over. Many parents are frightened for the very lives of their children and are not comforted that the actual risk to them is very low. Schools and businesses are being shuttered as if from a scene straight out of a post-apocalyptic horror movie.

Potentially, there is a much better way than just merely flattening the curve for the entire population to immediately render the virus less lethal and fearful to both older and younger populations, as well as resurrect our beleaguered economy.

Hypothesis:

Addressing older and younger cohorts differently could be a superior strategy to flattening the curve, both lessening mortality and minimizing economic fallout.

Dichotomous Strategy 1 - The Volunteer Inoculation Strategy:

The virulence of COVID-19 increases with age, accelerating rapidly starting at age 60 but disproportionately affects those that are age 70 and above. Age and known comorbidities are not the only variables that put an individual at increased risk from the virus. Undoubtedly, the health outcome from infection is multifactorial. Possible additional risk factors include smoking and other toxic exposures, medications used, obesity, diabetes, coping skills, history of major illnesses, and any number of other yet to be identified problems. All that aside, it may be useful to simplify a person’s risk to harmful outcomes from exposure to the virus as being exhibited in mostly a dichotomous distribution. Those under age 40 to perhaps 50 and without comorbid conditions who are risk factor free most often have mild consequences of a viral infection, whereas those over age 40 or with comorbid conditions have a higher risk of severe or critical consequences.

The current strategy of flattening the curve does not take this marked virulence difference into account. The dichotomous approach would be an attempt to steepen the curve with the younger risk factor free cohort (younger RFF cohort) whenever it can be safely accomplished, as well as continue to attempt to flatten the curve for the older high risk cohort (older HR cohort).

Example proposal to steepen the curve:

Because COVID-19 has a relative low morbidity/mortality to the younger RFF cohort then deliberate infection of this group with the virus can be thought of as a kind of vaccination.

Obtain healthy volunteers between the age of 18-39 (up to possibly 49) to be voluntarily inoculated with the virus and then quarantined until viral shedding has ceased and they are determined to be immune if reexposed to the virus. Current evidence shows an average incubation period of 5 days and infection period of an additional 20 days. Therefore, the average time between inoculation and immunity would probably average less than one month. Allow immune individuals (as well as those that developed immunity after contracting the disease naturally) back into the workforce with a special immune status.

Potential problems with inoculating younger RFF cohort:

It is reported that the younger population has a mortality rate of 0.2%. Even though this is substantially less than the mortality of the older HR cohort, it still would represent an unacceptable number of deaths among the younger RFF cohort. For example, there could be 10,000 expected deaths if 500,000 younger cohort were inoculated with COVID-19. Expense and isolation of younger RFF cohort during the quarantined phase.

a. Infection to immune status averages 20 days and may extend up to 37 days. This is based on current data of existing cases amongst all age ranges; conceivably the 20-37 day average period may be shorter in the younger RFF cohort.

b. An entire industry (medical personnel and physical space) would have to be created to safely keep the recovering volunteers.

Answers to the problems of inoculating the younger RFF cohort volunteers:

Unless an AV/Vac is introduced in the next 12 months, the death rate among the volunteers from the younger RFF cohort could be expected to decrease rather than increase from those that get community infection from the virus over time.

a. The goal would be to approach zero mortality for the volunteer group through careful selection of volunteers for participation in the program as well as close monitoring and early intervention of any severe disease that may occur. Only those volunteers deemed at least risk from the younger RFF cohort would qualify for selection as a volunteer. If any of the volunteers developed severe symptoms they would have the advantage of being under close observation and thus be treated immediately. As of this writing, Italy has more deaths from COVID-19 than any other country on earth. Yet, the data supplied from the ISS Italy National Health Institute, March 17, 2020, shows that out of 2003 deaths sampled, there were 17 deaths of those under age 50 for a 0.8% death rate. For those under age 40 there were 5 cases for a death rate of .2%. However, the news is even more encouraging as all 17 of the unfortunate deaths were males with “serious existing medical conditions”. These males would not have qualified to be volunteers. Thus, there were zero deaths for anyone under age 50 that did not have a serious medical condition.

b. Through voluntary inoculation, the time of infection would be precisely known and the progress of the volunteers’ health would be closely and effectively monitored. Any needed interventions would be efficaciously addressed and thus decrease mortality that would otherwise have transpired to the volunteer.

The expense to the world’s economy is unimaginable from one day to the next as long as a lockdown for the entire population mentality exists and dwarfs any expense generated from this proposal.

a. Volunteers would be generously reimbursed throughout the time of infection and quarantine.

b. Volunteers could potentially be isolated in otherwise vacant hotel rooms or government facilities.

Dichotomous Strategy 2 - The Low Risk Naturally Acquired Immunity Strategy:

Rather than using volunteers, this strategy would have the younger RFF cohort immediately return to work and resume normal life. COVID-19 spreads rapidly and many within the younger RFF cohort would be expected to become infected quickly and recover quickly, resulting in immunity.

Concurrently, the older HR cohort would be asked to shelter in place or provided a quarantine shelter. A simplified plan might be to recommend quarantine all those older than age 70. Or, a more detailed plan could be developed to identify all those at higher risk. Generous government assistance would be required for many within this group for living arrangements and care. Loved ones and friends would be reintroduced into their lives as those loved ones become immune and can no longer infect the HR cohort.

Flatten the curve isolates both the low risk and the vulnerable to prevent disease spread to the vulnerable. The Dichotomous strategies quarantine the vulnerable alone.

Benefits of a Dichotomous approach:

The entire fear climate of COVID-19 might be altered as the younger RFF cohort either lines up for volunteer inoculation or simply resumes life as normal. The boogeyman would have light shone upon him.

More direct efforts could be aimed at the older HR cohort to more effectively flatten out their curve. The older HR cohort who works could be allowed more time at home or a care facility to avoid the virus until an AV/Vac is available. Because the curve could be more effectively flattened in the older HR cohort the hospital resources needed by them would be more available as they become ill.

If the HR cohort were effectively quarantined and only those tested as immune would care for them then the death rate and morbidity requiring hospitalization for this group would be expected to plummet compared to flatten the curve approach alone. They simply would not become infected as there would be little chance for exposure. Such a strategy minimizes the risk of death and sickness to our most vulnerable population.

A pool of workers immune from the virus could be created for immediate and future employment needs so that vital services and goods continue uninterrupted and inspire confidence that our way of life can continue unimpeded.

The economy could see an immediate improvement as people realize that there will be workers that keep goods and services flowing without disruption.

More and more of the population will become immune and form a type of herd immunity more quickly. This may not result in complete herd immunity but those known to have immunity can move about and interact with those still at risk with impunity.

The need for personal protective equipment would be minimized. If caregivers are immune, it will free up resources for those that are still vulnerable. The need for respirators and hazmat suits would be eliminated for those immune healthcare workers caring or screening for COVID-19 patients and thus only a fraction of these items would be needed. Immune workers would be able to rely upon ordinary safety precautions.

Many persons under age 40 are expected to eventually be infected with mild or absent symptoms and, thus, will inadvertently serve as a carrier to infect others. This dichotomous strategy will eliminate the problem for those that attain early immunity by not becoming inadvertent carriers of the virus.

Discussion:

COVID-19 attacks dichotomously and we need to respond dichotomously. The nature of this disease is completely different for those over age 60 or those with comorbid conditions than those that are under age 40 and low risk. This difference needs to be exploited and not ignored. The economic and health crisis of this virus is equal or greater than major wars as the world becomes paralyzed with fear, internalizing that there are inadequate means to combat this common foe.

Those that might volunteer to become immune quickly and keep the world’s goods and services available could justifiably be seen as heroes. It’s not an overstatement that they could move among the infected as if they had superpowers. These immune volunteers would be impervious to getting sick again or spreading illness to others. We need a population of first responders, health care providers, and other workers critical to keep our economy running to be immune to the virus. We could establish an army of immune doctors, nurses, police officers, fire fighters, EMTs, military personnel, and the myriad of other people important to our economic infrastructure. Thankfully, the cost of their sacrifices should not include greater mortality. To the contrary, they might have less risk of death than others within their cohort.

If The Low Risk Naturally Acquired Immunity Strategy was used it would mean a large portion of our society would return to work and recreation activities and life would immediately return toward normalcy. The vulnerable would have greater protection against infection as those that care for them would shortly be immune from spreading the disease.

An analogy might help to understand why the COVID-19 dichotomous strategy is really nothing new if we were dealing with two separate viruses. Hypothetically say there were COVID-19 A and COVID-19 B diseases. COVID-19 A was mostly an inconvenience but potentially serious, whereas COVID-19 B may be deadly to a significant proportion of the population. If only disease A was hitting America then it would resemble a bad flu season and we would continue to go to work and play, unless sick, just as we have always done. But if we heard that disease B was threatening every age group then we would limit contact between everyone like we are now and pray for a vaccine or drug to fight it. The world is essentially getting disease A and disease B at the same time. Luckily we know who is susceptible to disease A. It is the younger RFF cohort. The older HR cohort is susceptible to disease B. We need different strategies for handling these two groups.

Note: Information about COVID-19 changes rapidly and statistics quoted in this opinion paper are expected to vary significantly over time. Percentage of those infected that become immune to further infection needs to be verified. This paper is based upon the assumption that the mortality rate for 18-39 year olds is 0.2% and probably much less than that for those in this age group that do not suffer from comorbid conditions. Should the mortality rate increase in this age group then many of the assertions made here would become invalid.

I do not advocate any individual independently exposing themselves deliberately to the virus.

Please refer to CDC or WHO for changes in statistics presented in this opinion paper.





Addendum:

Response to: “‘Can you get Coronavirus Twice?” Will there be a poor immunity response after exposure to COVID-19?

An excellent article by Bruce Y. Lee with Forbes entitled, “Can you get Coronavirus Twice? How Long Are You Immune After COVID-19?” questioned the wisdom of letting the virus run its course so herd immunity can be developed. This article serves as a good source for me to respond to potential problems with my proposal:

Following are some points the article makes:

Objection: February 14 article from Caixin entitled, “14% of Recovered Covid-19 Patients in Guangdong Tested Positive Again.”

Answer: There are several explanations why there was a 14% possible reinfection rate:

The obvious one is 14% of the population remains vulnerable to reinfection. Epidemiological studies are needed to determine if the 14% comes predominantly from the older HR cohort or distributed across all ages. More commonly those that are unable to mount an immune response to an exposure would be disproportionately represented by the elderly. My proposal only uses the healthiest amongst the younger RFF cohort and would be expected to be able to mount a good immune response. It has been suggested that the 14% is not reinfection but represents a dormant virus reemerging in the same patient. That sounds a lot like shingles reemerging from a remote Varicella (chickenpox) exposure after antibodies against the Varicella virus decline to where the body’s immune system cannot contain the virus. Such a reemergence does not typically happen in younger patients with a strong immune system. Testing has both false positive and false negative results and may be the culprit. If testing is at fault then there are methods to increase both sensitivity and specificity of a test (not described here) so immunity status could be more certainly ascertained.

Objection: The immunity may not last, the SARS research only suggests immunity for 2 years.

Answer: That’s true – we just don’t know yet whether there will be lifelong immunity or partial immunity, or immunity will be lost altogether in future years. But, it does appear that there is immediate immunity and that would allow the world to recover for this year and give us time to come up with alternative strategies for future years. Though a vaccine may be a long shot, it is possible. Antiviral agents seem to have a better chance of being developed. But what if there are no future treatments? Then the world will have to face a flattening of the curve strategy year after year and the world we know will be forever different. More hopeful and more likely in my opinion is that those that have previous infection will retain partial immunity and the mortality rates for survivors will fall over time.

2 years immunity as suggested by the SARS study would be great and give us needed time to prepare for the next round of infection. In a worst case scenario volunteers could be used year after year to keep goods and services intact rather than keeping the entire population in perpetual lockdown.

Objection: Herd immunity takes about 70% in order to be effective. There is already talk of those with stronger immune systems to get deliberately infected through natural infection to achieve the threshold needed for herd immunity.

Answer: It is unlikely that complete herd immunity will ever be achieved regardless of the strategy to do so. This is because the virus will likely mutate over time. However, it is also likely that those with a previous infection with the virus will react to it with much less mortality/morbidity than upon first exposure. Future reinfection with COVID-19 should look more like a common cold for all age groups. This is already true for most of those less than 40 years of age. The problem with COVID-19 is that it is a novel virus meaning never encountered by humans before. It will not be novel anymore after the first infection and the body should be far better equipped to deal with it.

Objection: The case fatality ratio is between 1%-3.4% which is too high to allow for intentional natural infection.

Answer: The reported mortality rate for those that would volunteer or return to work is not the same as the general population. It is reported as 0.2%. In all likelihood it could be much lower than that as demonstrated in the ISS Italy National Health Institute data. Those that smoke, are obese, have diabetes, have other comorbid conditions, or other to be determined criteria would be omitted. Those that may progress to sickness in the volunteer group would have early interventions and therefore better outcomes. Should the mortality rate increase in this age group then many of the assertions made here would become invalid.

Objection: Keep doing what you are doing to keep from getting the virus.

Answer: I agree. The only people that should volunteer for inoculation are those that are quarantined afterwards and not released back into the public until immunity is verified.

It would be terribly irresponsible for anyone to deliberately self-infect. By doing so would risk more vulnerable people they come in contact with every day and should never be done.





© 2020 Gary B. Ewing All Rights Reserved

Author Contact: garybewing.md@gmail.com