The COVID-19 end game

By now all countries on Earth have had a COVID-19 outbreak and are trying their best to combat the disease.  The good news is, although COVID-19 will linger longer than SARS, kills people faster than AIDS, and in many places the situation remains grim, humans have always won or survived throughout history.  

A question in the mind of everybody hunkering down around the world is: When will it end?  It depends on the definition of “end”.  Assuming COVID-19 will stay with us for the foreseeable future until the development of an effective vaccine, all one can achieve is to have sporadic incidences instead of widespread infections, or at least, a significant drop in new confirmed cases.  China, South Korea, and some European countries like Italy can offer a hint.

China imposed a lockdown in Wuhan on Jan 23, soon after the whole Hubei province and the rest of mainland China.  By Jan 23 confirmed cases were in the hundreds, but infections were obviously many more.  Since mid Feb, numbers of new confirmations were clearly dropping, first outside Hubei, then outside Wuhan, and last in Wuhan.  By Feb 20 newly confirmed cases in many provinces outside Hubei were down to single digits, almost 0, or 0; by Feb 29 the same thing happened to most of Hubei outside Wuhan.  By early March Wuhan was essentially free of new confirmed cases as well.  Granted, no new cases doesn’t mean no new infections, and asymptomatic patients exist and are still monitored.  But a practical baseline is one must tolerate small, sporadic infections (since nobody can’t eliminate COVID-19), so based on China’s experience, it will take about 4 weeks to contain a modest outbreak, 6 weeks to contain a severe outbreak.  On April 5, 2020 Wuhan still has about 600 COVID-19 patients at hospitals, out of a total 50K cases.  Indeed, since early-mid Mar, mainland China has seen close to 0 domestically new confirmed cases and been more concerned about imported ones.  

South Korea spurred to action around Feb 20.  By Mar 10, new cases had trended down.  They fell below 100 by late Mar but have stayed double digits or around 100 per day ever since.  Unlike China, South Korea didn’t impose a lockdown, and testing might be more prevalent per capita.  One can consider it took 3-4 weeks to contain COVID-19 in South Korea.

Italy recognized an outbreak after Feb 20 and implemented measures stepwise in early Mar.  After an arduous battle, by early April newly confirmed cases have started to drop, albeit still at large numbers (thousands).  It will likely take 2-3 more weeks to see new cases down to double digits, so 7-8 weeks is a reasonable timeframe.  Like in Wuhan, treating patients of course will take much longer.  Spain is similar.  Germany is doing better: with similar case numbers, the mortality rate is much lower.  

The US reactions started in early Mar, and the states imposed various restrictions in mid Mar.  By April 5 new case numbers are still increasing fast.  But it has been only 3 weeks, at most 5.   A prediction is that in 1-2 weeks we will see significant drops.  Returning to a baseline level will take much longer, since coming down from 20K to 20 is hard and slow, especially considering different states have different policies.

The rest of the world, such as India and others, are the big wild card.  One can hope that with hotter temperatures and better awareness, situations can be controlled with damage as small as possible.

Thus, based on experience, which is fairly constant among different countries, it will take 4-6 weeks to turn the corner.  The timeframe depends on one's policy and the level of implementation.  Turning the corner is not done, though.  If you start from a high level, it will take longer to go back to “normal”, and chance higher for an extended plateau phase.  And much effort is needed to treat that many patients.  So it will be months before one can relax, but one can see the light at the end of the tunnel fairly soon. 

      

Countries that apparently contain COVID-19, like China and South Korea, and those over the apex, like Italy and Spain, can set an example of what to do next.  The first thing is obviously to live with the virus but prevent a second outbreak.  It is doable since people don't need to set up everything anew.  Human activities should go back to "normal" gradually.  The second is to follow up the discharged, to see any lingering effects or whether they are truly recovered.  There are reports in China and South Korea that a few tested positive for RNA later, but it is possible that some of them were not really "cured" initially, or positive RNA doesn't mean active virus.  In any case, there is no indication that these people were seriously sick or infect others.  But since this is new, more studies are needed.   

The third is to examine a larger population for RNA or Ab, to learn more about COVID-19.  For example, the medical workers who cared for patients in Wuhan.  About 4,000 doctors and nurses were infected in Wuhan, most during the earliest phase of the outbreak.  The 30K or more medical workers joining the fight later reportedly were not infected or at least sick, but it is worth, easy, and important testing them.  Then sample the Wuhan population.  Since Jan 23 only those who were sick or had close contact with patients have been tested, while most residents were confined to their homes and never tested.  Testing a wider sample will tell us how many people were really infected and how many infections are asymptomatic.  It is possible that a COVID-19 predecessor has circulated for years, which might be mostly harmless but offers immunity to COVID-19.  This kind of detailed studies, which are common in every other diseases and takes time, will provide a complete understanding of COVID-19 and the outbreak.  

The fourth is, what about vaccines and effective drugs?  Vaccines will take time, but the status of clinical trials or results have been confusing, as no conclusions have been drawn about any particular drug or treatment three months after the outbreak.  The general picture is that most people heal by themselves, some people are given some medicines and get better, but not sure if the medicines help, and some people require complex treatments and machines just to survive.  It is possible that we need personalized medicines, which will take time to figure out.  At this moment, it is less about magic drugs than the medical infrastructure sustaining lives.  Even if a drug clears viruses from the system, if the patient has had other organ failure, he will struggle badly.  Just like one has a gun shot wound: a surgeon can always take out the bullet, but the wounded might still die.

I don’t believe the US will reach the predicted 100-240K deaths (even an optimistic estimate by American modelers), unless COVID-19 had been circulated for a long time before 2020.  COVID-19 is not as deadly a disease as many now fear, if dealt with correctly.  Admittedly wrong before, I am certain how people deal with COVID-19 now and later is more important than the disease itself, just like policies after 1929 made 1929 much worse and longer.