Sunday, March 01, 2020

Pandemics Are More Than Just About The CFR


Although everyone naturally worries about the mortality rate of a pandemic, even a relatively low mortality - high morbidity epidemic can provide major challenges to our economy, our society, and most importantly our health care delivery system.
While the case mortality rate (CFR) of COVID-19 is uncertain, it appears greater than what we see with seasonal flu, and it may well be significantly greater.  Time will tell. 
But what is apparent is it highly contagious, and some significant percentage of cases require hospitalization.  Those that are hospitalized, tend to require 2 to 3 weeks of care.  Even if most survive, that's an incredible burden on the healthcare system.

The notion that COVID-19 doesn't appear to be all that deadly - or that it mainly kills older people with comorbidities - may be reassuring (assuming you aren't old, or have comorbidities), but it doesn't really tell you how big of an impact it will have on our society or economy.

Even though I'm in the `high risk' category, I worry far more about the cascading indirect impacts of COVID-19 than I do the virus itself. 

Case in point, overnight local media (KIRO-TV) in Washington State is reporting that 25 1st responders who had contact with patients at the LTCF where two people have tested positive are going into home quarantine (video below)

While hopefully none of these 1st responders is infected, EMS services work with very little slack in their ranks. Take 25 people out of service for 2 weeks, and it will have a serious impact on their agency's ability to deliver essential services.
Now replicate this scenario in hundreds of city or county EMS services across the country over the next couple of months. We may well see a fair number of HCWs or 1st responders test positive, further depleting the workforce. 
These precautionary quarantines are probably prudent early in a pandemic, but will likely become increasingly less common once the virus begins broadly circulating in the community. By then, attrition due to actual infection, or the need to stay home to care for an infected loved one, will begin take its toll (see HCWs Willingness To Work During A Pandemic).
If schools close, many working parents - including HCWs - may be forced to stay home. If their kids get sick, that number goes up even higher. 
These same impacts are likely to be felt across a wide spectrum workplaces, and so even if we see a relatively low CFR, the impacts on the delivery of goods and services will probably suffer (see Supply Chain Of Fools (Revisited).
We could see shortages and/or delays in everything from food deliveries to prescription drugs, lapses in the delivery of public utilities (water & electricity), or replacement parts for your car or computer.
In 2005 Dr. Michael Osterholm, director of CIDRAP, likened a severe pandemic to an 18-month global blizzard, where nearly everything is shut down. Many will be without a paycheck, either due to their refusal to work and risk exposure, because they are out sick,  or because their jobs are simply no longer available (see Baby, it's Cold Outside).

More recently, in his 2017 book Deadliest Enemy (see my Review: Deadliest Enemy: Our War Against Killer Germs), Dr. Osterholm revisited the idea of our JIT (just in time) economy, and wrote:
Ironically, the ways we have organized the modern world for efficiency, economic development, and for enhanced lifestyle -- the largely successful attempts to transform the planet into a global village -- have made us more susceptible to the effects of infectious disease than we were in 1918.
And the more sophisticated, complex, and technologically integrated the world becomes, the more vulnerable we will be to one disastrous element devastating the entire system.
While hopefully we can find ways around many of these challenges, we are almost certainly going to see some significant disruptions to our lives in the months ahead.  I can't tell you right now what they will look like, or how bad they may be.  
It will likely vary wildly by location. Some places may come away relatively unscathed. 
But with pandemics, you have to prepared for surprises.