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Flattening the curve: A look behind the numbers and what’s next for Utah and the nation

Understanding what flattening the curve means for you

A pedestrian crosses 200 south at Main Street in a nearly empty downtown Salt Lake City during the lunch hour on Friday, March 27, 2020.
A pedestrian crosses 200 South at Main Street in a nearly empty downtown Salt Lake City during the lunch hour on Friday, March 27, 2020.
Steve Griffin, Deseret News

SALT LAKE CITYAs of Saturday, Utah has 603 cases of COVID-19, two deaths and is 13 days into the “urgent phase” of a new three-pronged plan to deal with the novel coronavirus.

The plan, which emphasizes extensive social distancing, limiting group gatherings, school closures and travel restrictions now also includes a directive to “stay home, stay safe,” as announced by Gov. Gary Herbert Friday afternoon.

Infographic by Alex Cochran

All these efforts are attempts to flatten the curve — to slow the spread of the virus and decrease the number of deaths.

Are they working?

Utah’s numbers — though significantly lower than those in New York, which leads the nation with 52,318 confirmed cases as of Saturday — are increasing steadily, though not exponentially at this point.

Utah officials are also optimistic about the low percentage of tests coming back positive at 5%, far lower than other states — yet only 11,312 people (around 0.3%) of Utah’s 3.1 million residents have been tested.

Patients wearing face masks and personal protective equipment wait in line for COVID-19 testing outside Elmhurst Hospital Center on Friday, March 27, 2020, in New York. The new coronavirus causes mild or moderate symptoms for most people, but for some, especially older adults and people with existing health problems, it can cause more severe illness or death.
John Minchillo, Associated Press

New York, a state of more than 19.4 million people, has done 155,934 tests as of Saturday — nearly 0.8% of the population. The positive return rate is about 33%.

Across the country in Washington, health care workers have 52,738 test results for more than 7.5 million residents, around 0.7% of its population. The state’s positive return rate is just about 7%.

Utah has had two COVID-19 deaths. But because the state hasn’t been forced to turn ice rinks into morgues, and doctors aren’t yet grappling with which patients get ventilators, the economic blows seem more painful to some than the virus itself, and in some parts of Utah, patience with precautions is wearing thin.

In Washington, D.C., President Donald Trump expressed hope for getting the economy back on track by Easter, a scenario called unlikely by health experts, while in Utah, a group of rural leaders wrote to the governor, asking that he “discontinue the path of destruction.

When the 17 rural county commissioners sent their letter on March 17, they emphasized the United States had only 90 deaths and the panic was overstated. Eight days later, the national death toll had risen to 942 and as of Saturday the number was 1,944 deaths.

While there are still many unknowns, experts say the next 10 to 14 days will provide significant information — both for Utah and the rest of the country — as to whether social distancing and case isolation strategies were quick enough and strong enough to make a difference.

Health researchers expect to see signs of impact two to three weeks after interventions are put in place; however, such signs of progress must be understood and managed correctly.

Pull the plug on interventions too early, said Mark Lurie, an associate professor of epidemiology at Brown University School of Public Health, and all “the isolation that we’ve endured over the last couple of weeks is going to be for nothing.”

Dan Brown, former KSL helicopter pilot and current Intermountain Life Flight pilot, and his crew lift off Wednesday, May 27, 2015, from Provo’s Intermountain Health Care.
A Life Flight helicopter lifts off from Utah Valley Hospital on Wednesday, May 27, 2015.
Scott G Winterton, Deseret News

Care capacity in Utah

Utah has 50 major medical hospitals — 26 on the Wasatch front. (The count may not include some that are only rehab hospitals or other speciality hospitals that wouldn’t treat emergent cases.)

Utah officials have been working to create a statewide database with the number of intensive care unit beds, ventilators and other important data points, but it was not done as of Friday, Jill Vicory, director of the Utah Hospital Association told the Deseret News in an email.

While individual hospital systems are “well aware of their capabilities” and working to maximize capacity, “these numbers have not been rolled up into an aggregate state or regional number,” she wrote. “UHA has not collected these stats for several years, and when we did, it was voluntary.”

However, a Kaiser Health News analysis of hospital financial cost reports, which are filed annually to the Centers for Medicare & Medicaid Services, lists a total of 562 ICU beds in the state of Utah.

A Deseret News review of each Utah hospital in the American Hospital Directory found 972 ICU care beds listed for the state.

Despite the lack of publicly released numbers, health officials in Utah have been working to stay on top of this situation “seven days a week around the clock since January,” said Jenny Johnson with the Utah Department of Health.

Their No. 1 goal is to “keep up with the number of sick patients and not collapse our system,” she said.

If the number of cases suddenly spikes and floods the health care system, there could be more people who need an ICU bed than are available. There would be people who need a ventilator who can’t get one. And deaths begin to skyrocket.

That is the worst-case scenario that health experts all over the country are trying to avoid — yet still plan for.

An emergency room doctor at a hospital in Salt Lake City told the Deseret News they are briefed daily on the number of COVID-19 patients, ventilators, protective gear and ICU beds and that currently their hospital is “under capacity.” But they’re preparing for a “surge” over the next few weeks, said the doctor, who asked not to be named as they were not authorized to speak to the media.

The doctor mentioned all discussions are influenced by the situation in New York, “and seeing how literally overnight their hospitals were overcapacity and they were out of ventilators.” President Trump Saturday said he was considering a short-term quarantine of “hot spots” in parts of New York, New Jersey and Connecticut.

“When I first heard about the virus, I wasn’t too worried,” the doctor said, “because I thought in the United States our health care system is so good we would handle it better than other countries. It didn’t take me long to realize that couldn’t be farther from the truth.”

Intermountain Healthcare hospitals — there are 11 on the Wasatch front — are in “good shape,” for capacity because they’ve postponed elective procedures, said Jess Gomez, associate director of media relations for Intermountain Healthcare, in an email. He declined to answer another written question regarding the specifics of the system’s ICU capacity.

One nurse said her Salt Lake City hospital is already looking into how it can convert other hospital rooms into ICU rooms, as well as cross-training nurses who normally help with elective surgeries, since all such surgeries have been canceled. She said they’re also looking into using anesthesia machines as ventilators.

The state already knows that ventilators will be in high demand and short supply, Utah state epidemiologist Dr. Angela Dunn said in a recent Utah Health Department press briefing, although the state wouldn’t provide a number of how many Utah has.

An analysis by the Institute for Health Metrics and Evaluation at the University of Washington predicted Utah would need 157 ventilators at the peak of the crisis, shown by its modeling to be April 24. The modeling also shows that Utah would have sufficient total hospital beds, but be short 121 ICU beds. Those University of Washington projections come with a lot of uncertainty and a range of outcomes, depending on how Utahns respond to the crisis.

In Utah, roughly 10% of current cases require hospitalization, with half of those cases needing intensive care. Based on those percentages, that would mean roughly 50 Utahns are now in the hospital, with no more than two dozen people in the ICU, based on Dunn’s comments at press briefings on Thursday and Friday.

Medical workers load oxygen and disinfect surfaces of an ambulance outside a COVID-19 testing side at Elmhurst Hospital Center on Friday, March 27, 2020, in New York. The new coronavirus causes mild or moderate symptoms for most people, but for some, especially older adults and people with existing health problems, it can cause more severe illness or death.
John Minchillo, Associated Press

In New York City, hospitals are nearing capacity and officials are looking toward other makeshift overflow facilities.

Bloomberg is tracking the number of available beds in the city and puts the number around 23,000, although it notes they’re still missing information, and “hospitals haven’t been disclosing their occupancy or their data on intensive care units and lifesaving ventilators.”

Across New York state, there are around 53,00 beds and nearly 3,000 ICU beds, according to U.S. News & World Report. But experts estimate a need far beyond that — 110,000 beds and the potential for as many as 37,000 ICU beds.

On Wednesday, Gov. Andrew Cuomo said that the city’s numbers showed slight signs of slowing — instead of hospitalization rates doubling every two days as they were last Sunday, it appears the hospitalization rates are doubling every 4.7 days.

While that offers a glimmer of hope, the most accurate numbers in a pandemic are those that stay consistent, or continue to go down, over days and weeks.

The curves

The reason to care about hospital beds is because health care capacity is the driving factor in a graphic you’ve probably already seen — the one that shows two contrasting bell curves: one tall and skinny and one shorter and wider.

The skinny bell curve represents what would happen over time if nothing in daily routines changed, as people spread germs and cause an exponential growth of coronavirus cases.

Unchanged behavior could result in 7 billion infections and 40 million deaths globally, according to a recent report from the Imperial College COVID-19 Response Team in the United Kingdom.

The flatter curve — one which stays under a line representing health care capacity — represents a slowing and spreading of cases thanks to social distancing, case isolation and vigilance with personal hygiene, like hand-washing.

It doesn’t stop the disease and people still die because they’re already in the pipeline, said Drew Harris, a population health analyst at Thomas Jefferson University in Philadelphia. But the health care system stays intact and patients can be cared for in the ICU, not a tent in a parking lot — whether for COVID-19 or any other emergent situation, such as heart attack or stroke.

The Imperial College’s projections of lives lost in a flattened curve situation are less clear — it all depends on how quickly and intensely a country responds to try and stop the virus.

Utah had its first reported COVID-19 case in the state on March 6, and schools have been closed for two weeks, with public gatherings curtailed nearly as long.

Medical workers provide drive-thru COVID-19 testing at University of Utah Health’s South Jordan Health Center in South Jordan on Friday, March 27, 2020.
Medical workers provide drive-thru COVID-19 testing at University of Utah Health’s South Jordan Health Center in South Jordan on Friday, March 27, 2020.
Spenser Heaps, Deseret News

If Utahns lock down for long enough and respect and obey the recommendations, then there’s “every reason to believe that many of the chains of (virus) transmissions would be interrupted,” Lurie said.

But it’s still too early to know exactly what Utah’s curve will look like — and just how steep it will climb before tapering.

The need for testing

Predictions are difficult because “we don’t have any good sense of how many actual cases are out there,” said David Dowdy, an associate professor in the department of epidemiology at the Johns Hopkins Bloomberg School of Public Health.

In a partnership between Politico and The COVID Tracking Project, volunteers are gathering data from every state on the number of tests and the percent of positive tests.

Trump recently said the number of tests run in the United States has exceeded 300,000 — surpassing the number of tests conducted in South Korea.

However, because of massive population differences between the U.S. (327 million) and South Korea (51 million) the per-person testing rate is much more instructive, NPR pointed out.

In South Korea, where it has been successful at flattening the curve and protecting its health care system, it tested 1 of every 170 people. In the United States, the figure is 1 in every 1,090 people, according to NPR.

Such small levels of testing are like shining a flashlight on the side of a mountain — you can only see what’s illuminated, not the entire scope of the problem, said Harris.

“Until we have much better testing, we don’t know the magnitude of the outbreak,” he said.

In Utah, 11,312 people have been tested, a small percentage of the population. However, Utah officials are encouraged by the low number of virus-positive tests, about 5%.

Perhaps Utah isn’t seeing as “much disease because maybe our messaging to the public about social distancing measures are working,” said Johnson. “People who have mild symptoms are being able to recover at home, who may not be tested, which is what we’ve been asking them to do.”

Initially, because of a shortage in Utah, tests were limited to those who met specific criteria. However, the state now has sufficient tests that anyone who experiences symptoms of shortness of breath, fever and cough and who gets approval from their doctor can get tested, Johnson said.

A patient, center, is transferred to a medicalized hotel during the COVID-19 outbreak in Madrid, Spain on Tuesday, March 24, 2020. The coronavirus is winning a war of attrition waged against health care workers throughout the world but more so in Spain, where necessary equipment to shield them from contagion and enough testing kits for the new virus have been lacking for weeks.
Bernat Armangue, Associated Press

“We need the public to understand that yes, we can test everyone who needs a test,” she said, “but not everybody medically needs a test right now.”

However, because experts believe that the virus is still spreadable by those who are asymptomatic, they encourage everyone to behave as if they have it, to more effectively prevent the spread.

The hammer and the dance

Trying to manage a state’s curve requires a careful balance between the “hammer and the dance,” a concept outlined by Tomas Pueyo in a viral in-depth analysis, which while thorough, has also been criticized because it comes from a non-health expert. Pueyo has two masters degrees in engineering and an MBA from Stanford.

(The Deseret News asked a few epidemiologists about the report, and while they took issue with a few small interpretations of data, they agreed the general construct was accurate and illustrative.)

The hammer, Pueyo argues, is the sharp and immediate containment efforts, followed by the fluid dance of navigating a return to a new normal, while still managing hot spots — much like the work done by firefighters after a wildfire to prevent a resurgence.

Across the world, countries have demonstrated a variety of hammer attacks — some swift and severe, as in China, and others more sluggish, as in Italy and Spain — where both countries have already surpassed China in their total number of deaths.

As of Saturday, China had 3,295 COVID-19 deaths. Spain had 5,812, while Italy reported 10,023, although Italian officials are admittedly looser in their descriptions of the cause of death, potentially glossing over underlying health issues, according to professor Walter Ricciardi, scientific adviser to Italy’s minister of health, as reported in the Telegraph.

Both Italy and Spain have since locked things down and may be near their peaks — but not before exponential damage was sustained.

The intensity of an outbreak is calculated using R0, (pronounced R naught), referring to or the virus’ reproduction number, or how many people one sick person infects. At the peak of the spreading in China, each person was thought to infect about 2.5 other people.

If one person infects nearly three others, who then each infect three others and so on, it’s easy to see how cases spread exponentially.

“The momentum of a pandemic is incredible, especially this particular one that spreads so easily among asymptomatic people,” said Harris.

That’s why harsh measures are needed to lock things down, isolate and quarantine.

In Utah, the state will remain in an “urgent phase” for at least eight to 12 weeks, with a goal for eight — according to the timeline outlined in Herbert’s plan — until the reproduction number is closer to one, and cases slow or start to recede.

At that point, the state will shift into its stabilization phase, which Pueyo calls the dance, which includes deciding how much to “let up,” and what normal activity looks like.

Public health experts caution that it’s critical not to rush anything. Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases and the man who has become a national voice working with the Trump administration, has said several times: “You don’t make the timeline, the virus makes the timeline.”

Consider the responses of Philadelphia, St. Louis and Denver to the 1918 influenza pandemic.

Philadelphia flouted early warnings and insisted on holding its Liberty Loan Parade, packing hundreds of thousands of people into the downtown area. Within days, hospitals were full of sick people and the city lost nearly 12,000 to the illness in just four weeks.

Caskets arriving from the Bergamo area, where the coronavirus infections caused many victims, are being unloaded from a military truck that transported them in the cemetery of Cinisello Balsamo, near Milan in northern Italy on Friday, March 27, 2020.
Claudio Furlan, LaPresse via Associated Press

St. Louis instead decided to clamp down, essentially sheltering in place, resulting in a significantly lower overall death rate.

Denver started out like St. Louis, but then got impatient, with officials saying “we’ve got to get back to business,” said Harris. The city opened back up, the virus peaked again and more people died.

“The question for folks in Salt Lake City and the rest of Utah,” Harris asks, “is which of those three do you want to be?”

Contributing: Gillian Friedman

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