28 March 2020 Blog Post: COVID-19, An Update in a Week of Confusion

As we complete our first full week of ‘shelter in place’, now would be a good time to take stock in where we stand nationally and locally. As I have pointed out in previous posts (and have been hearing more and more from patients), the lack of consistent messaging from the CDC has made it difficult to understand the contours of this outbreak. Part of the reason that we are hearing mixed messaging is because, currently, #COVID-19 is highly regional, with some areas being heavily impacted (NYC Metro area), others about to be impacted (New Orleans, Los Angeles, Chicago, Detroit) and some areas with less burden of disease (North Dakota, USVI, Hawaii).

This regionality has led President Trump and Dr. Deborah Birx to begin a discussion of high, medium and low risk areas. Such would “help states make decisions about relaxing or enhancing the measures they have put in place to stop the spread of the coronavirus.” This is faulty thinking and stems from Dr. Birx’s HIV experience, which she has attempted to shoehorn into our response to coronavirus. This is classic ‘to a person with a hammer, everything looks like a nail.’ In HIV, early work focused on a small number of risk groups which, although oversimplifications, were effective in communicating risk reduction techniques intended to slow its spread.

Unlike HIV, coronavirus is spread primarily through respiratory droplets and is incredibly infectious. This makes the entire population is susceptible, unless actively infected, hospitalized or recovered.

In a recent press briefing, Birx stated, “When people start talking about 20% of a population getting infected, it’s very scary. But we don’t have data that matches that based on our experience.”

This is factually incorrect. In the NYC metro area, 30% of coronavirus tests are positive. Ah, Dr. Birx would counter argue, but we are only testing ‘high risk’ patients, not the general population so of course that number exceeds 20%.

At Santa Monica Primary Care, we have been testing patients in whom a positive test or a negative test would have some consequence. As I outlined before, we may test a patient with vague symptoms but is caring for a susceptible elderly parent. Or we may not test a patient with more typical symptoms who is already quarantined and doing well.

Cumulative percent of positive tests in our clinic have been as follows (date is the sample submission date):
3/11/2020: 0%
3/12/2020: 0%
3/13/2020: 0%
3/16/2020: 0%
3/17/2020: 0%
3/18/2020: 0%
3/19/2020: 14.2%
3/20/2020: 10.8%
3/23/2020: 12.1%
3/24/2020: 11.3%
3/25/2020: 14.8%
3/26/2020: 14.2%
 
Shelter in place for California began Thursday night 3/19/2020. Note what has happened to our clinic rates between 3/19/2020 and now – nothing. They are identical (I hadn’t noticed that until I wrote the sentence). Although we are not yet at 20%, we are not that far off.
 
So now is not the time to categorize regions as high, medium, or low risk. We are all at high risk. Now is not the time to relax social distancing and shelter in place orders. Now is the time to keep our prevalence rates stable so we can manage those patients who need Emergency care or who need ICU care without overwhelming our medical providers and hospital capacity. We need to all be doing this.

𝗦𝗶𝗴𝗻 𝗨𝗽 𝗳𝗼𝗿 𝗢𝘂𝗿 𝗡𝗲𝘄𝘀𝗹𝗲𝘁𝘁𝗲𝗿

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