Racing COVID

Swedish epidemiologist Anders Tegnell months ago warned that the battle against the pandemic is a “marathon, not a sprint,”  and his words should resonate for everyone in Anchorage now.

Alaska used the nuclear option against the disease back in March to “flatten the curve” as it was presented then, and the statewide lockdown was highly effective.

The state’s coronavirus response hub shows spring cases peaking at fewer than 20 per day in mid-March – when everyone was terrified of the new disease delivered by the SARS-CoV-2 virus – and falling to almost nothing by mid-April.

Those can now be considered the good, old days. The disease came creeping back in June, persisted at a relatively low and steady level through the summer, and has now exploded as cooler weather pushes everyone indoors, businesses close their doors and windows to keep out the cold, and kids go back to school.

The state is not unique in this regard. All across the cooler parts of the northern hemisphere, COVID-19 cases are on the rise as the seasons change.

Cold versus warm

Cases might be falling in India, where the weather is warm, but the University of Oxford website Our World in Data shows them going up, and going up rapidly, in Germany, France, Canada, Spain, the United Kingdom, Italy, the U.S., Russia, Sweden and even Norway, which had remained largely COVID-19 free up until now. 

The Swedes, who have been either praised or attacked for their moderate response to the disease to date, are now telling their citizens to take extra precautions to avoid infection.

The Local, an English-language publication that reports from Sweden, says citizens in the three regions with the highest rates of disease have been told to:

• Refrain from being in indoor environments such as shops, shopping centres, museums, libraries, swimming pools and gyms. Necessary visits to for example grocery stores and pharmacies are OK.

• Refrain from attending, for example, meetings, concerts, performances, sports training, matches and competitions. This advisory does not apply to sports training for children born 2005 or later.

• If possible avoid physical contact with people other than those you live with. According to the Public Health Agency, this includes for example attending or throwing a party or similar social gatherings.

In the 49th state – where the March-April lockdown wreaked havoc on businesses, especially in the service-industry sector – officials are reluctant to take such measures and are now blaming the increase in infections on Alaskans who refuse to wear masks in public.

Julie Taylor, the chief executive officer for Alaska Regional Hospital, Thursday suggested to The Anchorage Press that most of the people in the hospital there caught COVID-19 from someone who wasn’t wearing a mask.

How patients would know this (given that so many attempts to trace the infection anywhere have tracked back to unidentifiable “community spread”) and how Taylor verified this information was not reported, but she was quoted saying this:

“I know that there’s naysayers out there, and honestly you guys are the problem.”

The anti-maskers

Where this mob of the unmasked is hanging out is unclear. Anchorage has been masked up for months, and a quick check of some city businesses Thursday evening – a Costco, a Carrs, a Lowes, a Walmart, and a mall  – led to not a single sighting of an unmasked shopper inside those spaces.

Certainly, it is possible, probable even, that there was someone there without a mask, but it has been rare to see someone without a mask in Anchorage businesses for a couple of months. Compliance with Anchorage’s mandatory masking would appear to be 95 percent or better.

And yet the city’s infection rate keeps going up.

The Anchorage Health Department on Wednesday issued a “health advisory” warning the rate of infection had reached 40 cases per day – four times the 10 per day the state considers a dangerous rate of spread.

The municipality’s advice was to “stay home” or “wear a mask and stay at least six feet away from others in public” even when engaging in “indoor exercise or sports” at the gym or participating in “Halloween activities.”

The latter guidance suggesting it is OK to exercise indoors (other than in your own home) or hold a Halloween party directly contradicts the advice to “stay home.” Meanwhile, the advice to people to stay six feet apart has been increasingly overlooked since masks became the norm.

And why wouldn’t it be? On national TV, you can watch masked up, National Football League (NFL) coaches march across the field after games and hug each other.

The city seems to be behaving much like the NFL.

In the wake of a spread of COVID-19 that makes March look like nothing, Anchorage has closed no businesses and mandated no new restrictions. In a video show, Health Director Dr. Heather Harrison merely warned that “COVID is everywhere in our community,” and “we are on a dangerous path and the solution is simple.

“We must wear a mask and keep a distance from people outside of our households.”

There is no evidence to indicate the solution is that simple, but the rest of the video made clear the muni’s fear of another shutdown, given the economic disaster driven by the earlier shutdown.

That marathon

This is exactly the scenario of which Tegnell warned when he observed that the battle against COVID-19 is a marathon not a sprint. Having sprinted at the start, and having run far out in front of the race, Anchorage now finds COVID-19 roaring past, and the city is apparently incapable of responding.

A gang of scientists from around the world earlier this year built a model of what appears to work to reduce the spread and posted it at  MedRxiv a couple of weeks ago.

“We gather chronological data on NPIs (nonpharmeutical interventions) in 41 countries between January and the end of May 2020, creating the largest public NPI dataset collected with independent double entry,” they wrote. “We then estimate the effectiveness of eight NPIs with a Bayesian hierarchical model by linking NPI implementation dates to national case and death counts. The results are supported by extensive empirical validation, including 11 sensitivity analyses with over 200 experimental conditions.”

Masks proved the weakest of interventions in the examination. The study actually gave masks a negative score, but the authors said it was possible that in some situations they might help.

Overall, the rankings in order from the most effective measure to the least calculated by the reduction in the reproductive rate (R) of SARS-CoV-2  looked like this:

• Closing schools and universities – 41 percent most likely probability of reduction of R in a range of 23 percent to 56 percent.
• Closing some high-risk businesses – 36 percent in a range of 17 percent to 53 percent.
• Limiting gatherings to 10 people or less – 36 percent in a range of 17 to 53 percent
• Limiting gatherings to 100 people or less – 28 percent in a range of 9 to 44 percent.
• Closing most nonessential businesses – 29 percent in a range of 8 to 47 percent.
• Closing some high-risk businesses – 20 percent in a range of zero to 40 percent.
• Limiting gatherings to 1000 people or less – 13 percent in a range of minus-three percent to 31 percent.
• Issuing stay-at-home orders (with exemptions): 10 percent in a range of minus-two percent to 22 percent
• Mandating mask-wearing in (some) public spaces: minus-one percent in a range of minus-13 to eight percent.

There are pro-mask scientists who argue the benefit of masks is closer to the study’s maximum range of eight percent or even higher. But few if any believe masking is more effective than keeping people away from each other.

France announced a four-week lockdown that began Thursday.  Germany has closed bars, pubs, restaurants, gyms, cinemas and theatres, and announced a four-week restriction to limit household mixing to two households with no more than 10 people.

The Independent Scientific Advisory Group for Emergencies (SAGE) has called for a two-week “circuit breaker” lockdown to slow the spread in the United Kingdom. 

The thinking is simple. On a fundamental level, the spread of infectious disease – any infectious disease – is controlled by preventing human A from passing it to human B. Somebody in Hoboken, N.J. – a hotbed of COVID-19 death – isn’t going to give the disease to someone in Anchorage unless the virus can survive on the licked adhesive of a letter for however long it takes the U.S. Postal Service to deliver it.

If you go to the model to be found at epidemicforecasting.org and punch in masking as the only means to slow the spread in Anchorage, what you discover is that basically nothings changes. The number of infections go on increasing relatively unabated.

Even in a best-case scenario for masks alone – more than 60 percent of the population wearing them in public places (and Anchorage appears higher than that) with the maximum 8 percent reduction in the transmission of disease – an R of two today only drops to 1.85 in the days ahead.

To get the spread under one, which shifts SARS-CoV-2 from increasing to decreasing, the model calculates that masks would have to be more than 50 percent effective in stopping the spread.

Even the optimistic scientists at the University of Washington (UW), using a “Bayesian meta-regression of 40 studies measuring the impact of mask use on respiratory viral infections,” only calculated a 40 percent reduction in the R for 95 percent masking.

If the R in Anchorage today is put at a conservative two – meaning each person who is walking around with SARS-CoV-2 in their lungs is capable of infecting two other people – a 40 percent rate for masking alone leaves the R at 1.21, which fails to stop the spread.

Magic masks

It must also be noted that the accuracy of many of the 40 studies used by the forecasting team at UW’s Institute for Health Metrics and Evaluation have been widely questioned by scientists because many of those studies were done in clinical situations, and there are differences between how protective equipment is handled in hospitals and the real world.

In a peer-reviewed study published in Clinical Infectious Disease in 2017, scientists studying transmission in the wake of SARS-CoV-1 concluded randomized controlled trials (RCTs, the gold standard of medical studies) of masks conducted in hospital settings indicated masks were 59 percent effective against “clinical respiratory illness,” although notably “not viral infections.”

The results were significantly different for real world, “observational studies (which) provided evidence of a protective effect of masks at 13 percent and respirators at 12 percent against severe acute respiratory syndrome (SARS),” the study said.

Neither the IHME or EpidemicForecasting.org studies have been peer-reviewed. Both were conducted by respected scientists. Peer-review itself has been facing problems during the pandemic. The biggest peer-reviewed study suggesting masks have a major effect almost immediately came under fire.

The mask debate has in some corners simply come down to believers and non-believers. Beliefs are individual constructs that exist in people’s minds. You believe in God even if there is no way to demonstrate God exists.

Science is not a belief. It is a method for determining what ideas are supported by repeatable evidence. Gravity, for instance, is demonstrated by such evidence. If you throw the ball up, the ball comes down.

In the case of masks, the one thing the evidence makes clear is that they are not like condoms, which have been shown to block the spread of HIV/AIDS, another pandemic disease.

Masks are porous. Condoms are not. Masks leak. Condoms by design should not.

To get condom like protection in the case of SARS-CoV-2, people would need to wear plastic bags over their heads, which would be effective in stopping the spread of SARS-CoV-2 but limit the time one could spend in a public place.

You cannot long breathe in a plastic bag because of the build-up of your own carbon dioxide, a waste product of respiration. Suicide researcher Geo Stone decades ago reported that breathing in a sealed, 30-gallon garbage bag becomes uncomfortable after 15 minutes, and he estimated death would come after about 30 minutes.

Given the realities here, it is misleading to suggest to people that they can wear masks, go on about their normal lives, and expect the rate of infection in Anchorage to drop. That is just wishful thinking. There is no evidence-based reason to believe it.

Protecting the city

The evidence would indicate the only way to get the rate down is for Anchorage residents to reduce their interactions, which would mean staying away from each other and out of places where SARS-CoV-2 viruses could concentrate.

Disagreements remain about the extent of the aerosol spread of SARS-CoV-2, but a study by the Centers for Disease Control found that “adults with positive SARS-CoV-2 test results were approximately twice as likely to have reported dining at a restaurant than were those with negative SARS-CoV-2 test results.”

It added that “reports of exposures in restaurants have been linked to air circulation. Direction, ventilation, and intensity of airflow might affect virus transmission, even if social distancing measures and mask use are implemented according to current guidance.”

The sample size for the study was, however, small.

And in a democratic society, of course, there is always the question of how much government should do to protect people from risks and how much liberty people should have to make their own decisions about risky behaviors.

Decisions on COVID-19 have no black-and-white answers. There is no clear good or bad. But city officials should be honest with people instead of encouraging the belief that masks are a magic means of protection.

At this time, it would appear to be risky for some to be running in and out of Anchorage businesses, but the degree of that risk is itself dependent on individual factors – age, obesity and general health being key among them.

It’s hardest to gauge the risk for the young and healthy. If you want to judge it high, you can based on the horror stories the mainstream media has published about the rare, healthy young person struggling with serious COVID-19 complications. If you want to believe it low, you can just consider yourself bulletproof as many young people do.

But there is some data available to inform personal decision-making for those who are interested.

At this time, the state reports 8,009 active cases of COVID-19 and 67 hospitalizations. That translates into a hospitalization rate of about 0.8 percent statewide, but it appears higher in Anchorage where 54 of the 67 are hospitalized.

Exactly how many of those are people transferred to Anchorage hospitals from outside the area is unclear. Anchorage is reported to have 4,522 active cases. If all 54 of the hospitalized people are from Anchorage, the percentage hospitalized would rise to 1.2 percent.

That remains a pretty low number equal to the statewide death rate, dating back to March. Among the 6,524 Alaskans whose cases have been resolved, 77 have died.

To put this in perspective, that’s a death toll of less than 10 people per month. Unintentional injuries – the third leading cause of death in the state – kill an average of about 34 Alaskans every month, according to the state Department of Health and Social Services. 

Accidental death rates in Alaska and the U.S. have long been a major killer. They killed a record 170,000 Americans in 2017. Many of them were young people.

COVID-19 has to date killed more than 235,000 Americans. Most of them were old. And death rates have fallen significantly almost everywhere since the pandemic began.

“The overall 60-day mortality…decreased from 24.7 percent in March to to 13.3 percent in June,” Swedish researchers reported this week. “Adjusted relative risk of death was 0.56 for June.”

The researchers did not know why more people are surviving, but noted “improvements of management and care have probably been of great importance.” There were also other factors cited:

• A lower number of patients with co-morbidities.
• The more conservative treatment of patients, which early in the epidemic had been rushed into intensive care units (ICUs) and put on ventilators. It was later discovered that wasn’t always the best practice for COVID-19 patients.
• And “perhaps” a change “in virulence of the SARS-CoV-2 virus….A major deletion in the SARS-CoV-2 genome was associated with milder infection. Among 521 virus strains in Sweden with complete
  genome sequences, 19 different SARS-CoV-2 strain sequences were identified; 11 of which were identified in strains collected in March only. It will be important to investigate if the most prevalent SARS-CoV-2 strains in May and June had an inherent reduced virulence
  or had undergone genetic changes that reduced virulence.”

Some evolutionary biologists have suggested a weaker strain of SARS-CoV-2 will become dominant for the simple reason that the fewer people the disease kills the more infected people there are likely to be walking around spreading the virus to others.

Viruses are highly adaptable in this way as the flu virus has repeatedly shown. The CDC notes the problems this has caused in creating effective vaccines. The virus’s evolving nature makes it a shifting target hard to hit.

Vaccine effectiveness for the 2018-19 flu season was reported to be only 29 percent. Over the past decade, effectiveness has ranged from 60 percent (2010-2011) to 19 percent (2014-2015).

Along with being constantly changing, the flu and SARS-CoV-2 viruses share something else in common: They are deadliest for those already in poor health. Maintaining basic, physical fitness is protective against both diseases.

Age and so-called “co-morbidities” have been much discussed in the wake of the new pandemic, but the CDC has been warning for years about the increased risks of deadly flu among the old and obese, or those with a history of diabetes, stroke, cancer or a long list of other diseases, many of them considered chronic.

There are things you can do as an individual to increase your odds of surviving COVID-19. Staying away from others and out of enclosed spaces while the virus is circulating is one. Staying physically fit is another.

Or you could pull on a mask and believe you’re safe. There’s no real evidence to support that, but it’s OK to believe it. Everyone in New York did, and a quarter of the city’s transit employees are now reported to have caught COVID-19.

That is a higher rate of infection than the 19 percent aboard the Diamond Princess cruiseship, which some consider something of a test-tube experiment for the infective spread of SARS-CoV-2.

Both infected and uninfected passengers were held captive aboard the ship for two weeks, and some scientists later suggested that boosted the rate of infection.

The passengers were told to social distance, but how well they did that has been debated. And on a cruiseship, it is hard to really get away from everyone especially when crew members, some of whom were infected, continue to roam the ship.

It is much easier to avoid contact in a wide-open place like Alaska if you want to do so. But his is its own marathon of sorts. Most people have a hard time going for long periods without social contact, and some can barely go for a short time without close contact with friends and family.