The Trajectory of COVID-19 cases in Select Countries

The trajectory of COVID-19 shows a very different rate of reported new cases.

The trajectory for Italy is strikingly more steep than for South Korea. Some epidemiologists are offering the analysis that there are more elderly people Italy (23% over 65 yrs)  than in South Korea (13% over 65 yrs) as the primary reason for the difference. 

I would like to suggest it was more related to the policy decisions made to stop the spread of the virus, which included immediate isolation and quarantine as well as some methods that would be unacceptable in the U.S. or Europe, such as contact tracing through cellphone records. The government had data about every contact each individual with a cell phone had, enabling the government of South Korea to reach those contacts of infected individuals immediately to contain the spread by isolating or quarantining those that had come in contact with the infected individual. In contrast, according to CGTN (China Global Television Network) the "Mayor of Florence Dario Nardella has suggested residents hug Chinese people to encourage them in the fight against the novel coronavirus."  That was good in spirit, but resulted in a lot more than hugging one individual, where several people would embrace each other at once -- not recommended public health practice. By having groups of 3-4 people hugging each other, it was the opposite of WHO recommendations to practice social distancing. 

The analysis of public health measures will continue to unfold as the escalation of cases continues. But there is hope with the Italy trajectory. Yesterday, there was a drop in cases, that we hope indicates the end of the second peak that is typical in a highly infectious event. There may even be a third peak, but predictably lower.

"Self-isolation" vs. "self-quarantine". What's the difference?

I have been asked these questions, including the question in the title of this post. I thought it would be useful to share the answers, here.

How do “self-isolation” and “self-quarantine” differ? 

The short answer is “quarantine” is for anyone who does not show symptoms but may have been exposed to a contagious diseases; whereas, “isolation” is for anyone already infected or likely to be infected due to an exposure. Both are done to prevent transmission of the disease to others.

The recommended definitions for “isolation” and “quarantine” in the Model Public Health Act (that is not law unless it is adopted by a state legislature or a form of it) may have been adopted by any state in their public health laws. Keep in mind, every state has their own public health law, these are just recommended standard definitions, not law.

(30) “Isolate,” “Isolated,” or “Isolation” means the physical separation and confinement of an individual or groups of individuals who are infected or reasonably believed to be infected with a contagious or possibly contagious disease from non-isolated individuals, to prevent or limit the transmission of the disease to non-isolated individuals.

(53) “Quarantine” means the physical separation and confinement of an individual or groups of individuals, who are or may have been exposed to a contagious or possibly contagious disease and who do not show signs or symptoms of a contagious disease, from non-quarantined individuals, to prevent or limit the transmission of the disease to non-quarantined individuals.

The World Health Organization also similarly defines these terms in the International Health Regulations (IHR), but includes articles and animals as well as humans, unlike the Model Act definitions:

“quarantine” means the restriction of activities and/or separation from others of suspect persons who are not ill or of suspect baggage, containers, conveyances or goods in such a manner as to prevent  the possible spread of infection or contamination;

“isolation” means separation of ill or contaminated persons or affected baggage, containers, conveyances, goods or postal parcels from others in such a manner as to prevent the spread of infection or contamination;

·  What do we know about the risk of people going out once they are told to self-isolate? How likely are they to spread it? 

Our system of quarantine/isolation has always been based on the concept of the “social compact” that means the government gives you the maximum amount of freedom to protect public health in exchange for your agreement to restrict/burden your own freedom to the degree required to do that. So ethical people agree to this “social compact”. The problem occurs when people do not keep that agreement, that happens more often than you would think. For example. Tuberculosis patients agree to come in everyday for antibiotic treatment in exchange for going about their day with complete freedom of movement. However, TB patients often do not show up for their antibiotics especially if they are drug addicts, so eventually, the court will agree to an order after giving them significant due process to comply with the “social compact”. The consequences of someone with COVID-19 violating their ”social compact” has high consequences. This may indicate a higher likelihood of court ordered isolations or quarantines because when balanced against the harm, the burden on the individual will be reasonable to prevent that harm. But our constitutional due process requires that we give a reliable patient the maximum freedom to self-isolate in their home with only the minimum amount of confinement necessary to protect the public health.

The infection rate is about the same as flu and SARS although with different consequences.

·  Do public health officials have any way of keeping up with all of the people who have been asked to self-isolate or quarantine? Is a court order, required?

Canada did a remarkable job of self-isolation and self-quarantine of people with symptoms or exposure to SARS in 2003-4, when they identified these travelers and sent them home and asked them to call in each day with a reading of their temperature. They communicated via telephone or Skype. This is human resource intensive, but they allowed people to enter their temperature online each day, reducing the human resource burden near the end of the cycle of SARS. We should be able to do that. If someone missed calling in, a human followed up with a phone call or a visit.

The U.S. is asking its citizens to honor the social compact and use social distancing even if it is inconvenient, both for the safety of the individual and the safety of others. The U.S. or its states may even ask for self-isolation or self-quarantine of particular individuals, again asking them to honor the social compact. We can do it.

What is a pandemic vs. an epidemic?

The World Health Organization (WHO) on March 11, finally issued the official decree -- COVID-19 is now a "pandemic".

The WHO has criteria for phases of pandemic influenza and they have applied that criteria to Bird Flu and even SARS. There are three criteria that must be met, which you can see from the WHO graphic. First, that the disease is contagious to humans or animals; second, there must be a sustained human to human transmission; and third, it must have "widespread human infection". Even after 34 countries were reporting cases of human to human transmission of COVID-19, WHO had not yet determined this met the "widespread human infection" criteria and many were wondering what it took to meet that criteria, if not 34 countries?

It took 114 countries. 

The WHO Director-General in his remarks, said that "In the past two weeks, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled."  Further, " we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction."

This graphic shows the decision-framework WHO uses to assess where we are in the phases before and after a pandemic. The announcement on March 11 is the Phase 5-6/ Pandemic phase. Look for WHO to next consider "post peak" status, hopefully in the near future. Since China and the Republic of Korea have 90% of the cases and have now shown declines in new cases, that's a good sign for the rest of the world. The move toward "post peak" for these two major nation contributors to the number infected indicates other countries should follow that drop in reported cases in the coming weeks depending on the controls and government interventions. 

Let's hope for the post peak announcement this spring.

Contact tracing for airlines -- no more excuses

In 2005, after the SARS global incident, and in preparation for a Bird Flu, the HHS proposed a rule requiring airlines to collect contact information for each passenger in the event they needed to be contacted because of exposure to another passenger, that might be discovered after the flight had ended. The airlines objected loudly to this new administrative burden, citing additional costs and even space on their servers would be exceeded by collecting this information. They objected because of stricter privacy laws in Germany, and our reservation system is Amadeus, a German application used by most airlines. Because the information is stored in Germany, the privacy violation happens within the jurisdiction of Germany even though it is transmitted electronically, it is still in the jurisdiction of Germany requiring compliance with German law. 

Graphic of patient zero on a flight and the passengers who were infected with SARS.

Are these issues still a concern in 2020? It is now 2020, and a revised rule is being proposed again, prompted by the risk of COVID-19 spread, as of  Feb 12, 2020, 85 Fed. Reg. 7874. This follows a notice of proposed rulemaking in 2016, 81 FR 54229, following the MERS and Ebola incidents. This proposed rule was published as a final rule, effective Feb 27, 2017, 82 Fed. Reg. 6890, codified at 42 CFR 70-71. The changes in the rule were noted that the domestic portion of this final rule includes new regulatory language clarifying when an individual who is moving between U.S. states is ‘‘reasonably believed to be infected’’ with a quarantinable communicable disease in a ‘‘qualifying stage.’’ These determinations are made when the CDC considers the need to apprehend or examine an individual for potential infection with a quarantinable communicable disease. 

So what does this mean? The rule explanation further clarifies who can be "apprehended": apprehension of an individual is based on a variety of criteria in addition to an illness report including: Clinical manifestations, contact or suspected contact with infected individuals, host susceptibility, travel to affected countries or places, or other evidence of exposure to or infection with a quarantinable communicable disease. 

Since the Paperwork Reduction Act is triggered by the collection of information, and MERS and Ebola were cited as a need for the regulation, there is a directive on the time for collecting this information: While HHS/CDC currently has approval to collect certain information concerning illnesses and travelers under OMB Control Numbers 0920–0134 (Foreign Quarantine Regulations, expiration date 05/31/2019) and 0920– 0488 (Restrictions on Interstate Travel of Persons, expiration date 05/31/2019).

Now, back to the current interim regulation, the collection of information is an enforceable rule when final, but it requires an order from the Director of CDC to begin collection of personal information: By this interim final rule, CDC requires airlines to collect and submit via electronic means to CDC, beginning within 24 hours of an order from the Director, certain data regarding passengers and crew arriving on flights arriving in the United States from foreign countries. CDC believes that this is the only mechanism by which it can efficiently obtain the information it needs for a public health response to outbreaks of communicable disease and that current regulatory requirements are not sufficient, especially in public health emergencies. CDC will exercise enforcement discretion where appropriate.

So, on Feb 18 2020, the CDC ordered the airlines to begin collecting personal contact information for passengers and crew traveling from China (or having been in China within the last 14 days), citing the proposed rule published Feb 27. 

How is contact tracing for airlines working in the U.S. for domestic flights? Here's my personal story. Yesterday, March 11, 2020, while on a flight, I spoke with a passenger who had been on a flight with a passenger who tested positive for COVID-19. I asked him how he found out --- was contacted by the airline. I had hoped the answer was that he had been promptly contacted by the airline but it was not his answer. He said he heard it on the news.

No more excuses, it is time for airlines to accept their responsibility. CDC has the authority to order the airlines to collect this information. The economic impact analysis states there was found to be no additional cost to the airlines for implementing this rule. 

Update, 3-16-2020: The ICAO, an independent association of international airlines develop common guidance for airlines. Here is their directive on contact tracing: "Airport preparedness guidelines for outbreaks of communicable disease" issued by ACI and ICAO (Revised April 2009):
Note.: To assist contact tracing, a passenger locator card is available on the WHO website (www.who.int/csr/ihr/locator_card) and a copy is provided in the Attachment to these guidelines. The International Air Transport Association, assisted by relevant experts, is evaluating different electronic methods that could facilitate traveller tracing. 

How many states have declared a state of emergency?

As of March 14, all states except Oklahoma and Maine had issued declarations of a state emergency.

As of March 13, 34 states have now issued declarations of a state of emergency.

As states announce confirmed cases of COVID-19 we can expect to see more states with emergency declarations. Almost half of all states (24) have declared a state of emergency due to COVID-19 by March 11, 2020. 

By March 9, Newsweek wrote that 8 states had issued declarations of a state of emergency, all issued by the Governor using Executive power. These states are: New York, Washington, California, Kentucky, Utah, Florida, Maryland and Oregon.

By March 9, 8 states had declared a state of emergency for their state:

1. Saturday, Feb. 29, 2020, Washington Governor Jay Inslee was one of the first U.S. governors to declare a state of emergency,

2. Wednesday, March 4, California Governor Gavin Newsom to declare a state of emergency

3. Sunday, March 1, Florida Governor Ron deSantis declared a public health emergency

4. Thursday, March 5, Maryland Governor Larry Hogan declared a state of emergency 

5. Friday, March 6, Utah Governor Gary Herbert announced a state of emergency

6. Friday, March 6, Kentucky Governor Andy Beshear declared a state of emergency 

7. Saturday, March 7, Florida Governor Ron DeSantis declared a level 2 state of  emergency (which followed a public health emergency declaration on March 1.)

8. Sunday, March 8, Oregon Governor Kate Brown declared a state of emergency

According to By March 11, 24 states had declared a state of emergency for their state:

Wednesday, March 11, Washington, D.C., Mayor Muriel Bowser declared a state of emergency.

Check the interactive map of states with emergency declarations on the National Governor's Association page for COVID-19.

Amerithrax changed our way of communicating with mail; will COVID-19 change our way of meeting?

Amerithrax changed our way of communicating with government officials and with each other. Mail sent through the U.S. Post Office could not longer go directly to Congress, but had to be sent to a testing facility in Ohio before eventually being received by the recipient often weeks later, and looking a bit "fried." We learned to conduct government business online through email, and through interactive forms on websites.

Announcements of cancellations of mass gatherings like the NBA, and universities, has pushed us to use online platforms for communication. We have always had them, but now they are our ways of communicating while avoiding the risk of contracting a pandemic disease. Will we become comfortable with them and find they increase our efficiency, like email did? Will we begin to replace in person meetings at a much greater rate after the COVID-19 pandemic subsides, leaving our lives changed forever, like Amerithrax?

Only time will tell, but if history is a lesson, our in person human contact may be changed forever.