NOTE: Dr. Michael S. Saag is professor of Medicine and Infectious Diseases at the University of Alabama at Birmingham. He is world-renowned for his work on the HIV virus. He asked us to print his assessment of the coronavirus reflecting his opinion, not necessarily representing the opinions of UAB or the University of Alabama System. He passed this on to us in the form of an open letter to the citizens of Alabama. Follow other stories in our live updates.

Fellow citizens,

Our State is about to be hit by a major storm and, unfortunately, we are not nearly ready to respond.

The COVID-19 pandemic is sweeping the globe, our nation, and our state. We can see it coming. It’s real.

If this were a Category 5 hurricane bearing down on the coast of Alabama, predicted to hit in a day or two, we would have already heard hurricane warnings and we would have a sense of what to do. But COVID-19 is so new, so unique, we have trouble comprehending what it is and we don’t know what to do.

The coronavirus is already in Alabama. We just don’t know the extent yet because our ability to test for the virus is restricted to the most severe potential cases and it takes a few days for the results to return. Our case load is going to get exponentially worse over the next six – 10 weeks, and the epidemic in our state will be especially noticeable once testing becomes more available.

Here’s why:

· Like other coronaviruses, the SARS-CoV 2 virus, which causes COVID-19, is spread by droplets, typically dispersed by coughing or sneezing.

If the droplets land directly on someone’s face, infection will almost certainly follow. But most often, the droplets land on surfaces that are touched by another person, and then transferred from that person’s hand to their face by touching their nose or mouth.

Based on knowledge from other coronaviruses, the virus can remain infectious on the surface where it landed for up to one week. So touching an object that is contaminated by the virus, such as a door knob, a water faucet, or a gas pump handle, for example, can readily transmit the virus. Of note: The virus is not transmitted through the air, so masks don’t help in folks who are uninfected (except perhaps to keep someone from touching their face)

· The SARS-CoV 2 coronavirus is a new infection for humans.

This means that anyone who gets infected with the virus has no baseline, protective immunity and will become sick to some degree. Fortunately, the symptoms of infection are very mild to moderate for over 80% of people infected.

Unfortunately, the likelihood of severe infection, and death, increases with age. Someone over the age of 80 has up to a 40% mortality risk, whereas a 20-year-old has < 1% risk of mortality. Those in between have higher risks of death proportionate to their age.

· Once we are able to test widely, we will identify the large number of undiagnosed patients. Massachusetts just started more widespread testing this week and colleagues of mine at one of the larger hospitals diagnosed 100 new cases in the last 2 days. Once we determine who is already infected in Alabama, we can expect a doubling of the number of cases every 5 – 6 days if we do nothing.

What else happens if we do nothing?

Based on current estimates, up to 70 to 120 million people in the US will contract the infection. That is ~1/3rd of the entire US population.

Here is a scenario to illustrate what seems likely to happen in Alabama over the next 10 weeks:

· With a doubling rate of infection of 5 – 6 days, cases rise exponentially over time.

· This means that we can go from 50 cases to 25,000 cases in 10 weeks.

· If 20% (5,000) of these patients are significantly ill, at least half of them will need to be in the hospital (2,500).

· Of those, at least half will need to be cared for in the ICU (1,250). And once in the ICU, they could remain there for weeks, clogging the ability to admit new patients to the ICU.

· And this scenario is only after 10 weeks; at 20 weeks from now, there could be up to 500,000 total cases or more in Alabama (you can do the ICU math).

UAB hospital has up to 300 ICU beds; other hospitals in Alabama have fewer ICU beds. And in all hospitals in Alabama today, most of those beds are already occupied. It is easy to see that hospital beds, especially ICU beds, will be in short supply as the coronavirus epidemic unfolds.

So the question then becomes: Where do the new, coronavirus patients with severe disease go?

Italy currently gives us some tragic insight. In Lombardy, Italy, last week, up to 200 patients needed admission to the hospital. But there were no more beds available. So the physicians had to scour the hospital making difficult decisions about which patients were too sick to recover and discharge them home to die in order to make room for those who had a chance to live. And I just heard from a colleague in Switzerland. They are on the verge of having to make the same decisions. No one wants to ever be in that gut-wrenching position.

The biggest concern is not the absolute number of infections; rather, it is the timing of when these infections occur.

Even if we don’t change the total number of cases that will occur in Alabama, delaying the time when they become infected will decompress the pressure on the limited hospital beds in the state, especially ICU beds. As illustrated in this New York Times graphic: The absolute number of cases in each curve is the same. What’s different is the time of infection. If we can simply delay the number of new cases, we have a chance to broaden the curve and save our fragile healthcare systems, and by extension ourselves, from peril.

What can you we do?

· Understand the details of how the virus is spread and take every precaution to protect yourself and your family.

· Specifically we should:

o Avoid large gatherings of people (concerts, religious services, auditoriums)

o If you are in charge of organizations that sponsor large social gatherings, cancel or postpone events. Now. Webcasting is a good alternative for many meetings.

o When in a crowd, use ‘social distancing’, staying at least 4 – 6 feet apart if possible

o Be mindful of surfaces touched (especially handles, of all types)

o Use your knuckle or elbow to turn on light switches

o Use a paper towel to lift gas handles at the pump

o Wash hands thoroughly (at least 20 seconds) with soap and water after any potential exposure, and frequently throughout the day for good measure (use of hand sanitizer with > 60% alcohol will suffice in lieu of soap and water)

o Keep a bottle of sanitizer at the entrance of your house; use it upon entering and leaving

o No handshaking (!). Elbow bumps will suffice.

o No hugging or ‘social kissing’ when greeting friends or relatives

o Use sanitizing wipes on surfaces in public areas prior to use (e.g., grocery cart handles, gym equipment, trays)

o If you feel sick (or not ‘right’): STAY AT HOME. Do not go out and risk infecting others

o If you feel very ill, contact your provider for guidance on where to be seen.

o If you feel you have COVID-19, and are not very ill, it is important to be tested outside of a doctor’s office or an emergency room. (We can’t do that in Alabama now; this needs to change)

o Help the state purchase tests for COVID-19. ASAP.

o Once tests are more readily available, we should set up testing sites in areas outside of existing clinics, hospitals, and emergency rooms throughout the State.

Folks, the virus is here. The clock is ticking on how we, as a community, respond. If we wait too much longer, our healthcare system will become destabilized from the onslaught of cases. This will result in difficulties for those with COVID-19 for sure, but also for everyone else who doesn’t have the infection and needs medical care for other conditions (heart attacks, strokes, cancer, and the like).

Returning to a meteorological metaphor, we currently have a “hook echo” on the radar screen. The tornado is already touching down. It’s time for us to get to our “safe places” to minimize destruction of our healthcare infrastructure and loss of life.

We are in this together. Let’s act now!

Michael S. Saag, MD, is Professor of Medicine and Infectious Diseases at the University of Alabama at Birmingham.