With the pandemic continuing to rage across the U.S. and around the world, the country’s hardest-hit areas are starting to open up.
And while few can say how or where the next outbreak will occur, many epidemiologists remain grim. At a news conference on Tuesday, Dr. Anthony Fauci described the disease as his “worst nightmare.”
“Oh my goodness,” he said. “Where is it going to end? We’re still at the beginning of really understanding.”
With much about the disease still unknown, the outcome of the next few months could range from benign to catastrophic. While some broad contours of how the disease behaves have become clear, nobody knows for sure what will happen.
Here are five factors that epidemiologists TPM spoke with are watching for to get a sense of what the next months have in store.
Post-opening spikes
The biggest — and most obvious — factor will be the presence and size of spikes in infection rates in communities that have reopened. Epidemiologists and public health officials look to hospitalization rates, with the idea being that it takes roughly two weeks for the virus to incubate, spread, and infect people seriously enough to require a hospital stay.
The country has gotten an early look at what this might mean with new data suggesting that COVID-19 hospitalizations have risen sharply in the two weeks following Memorial Day.
Dr. Susan Hassig, a Tulane epidemiologist, told TPM that states like Arizona and Florida have been seeing “a continual upward direction in terms of cases.”
“We’re two weeks after Memorial Day, and we were very worried about what impact it would have on case occurrence, particularly in the New Orleans metro area, because traditionally people go relax, party, and have crawfish boils,” she said, adding that in Louisiana’s, so far, the numbers do not seem as concerning.
“We saw evidence that people engaged in those activities — we’ve seen a little bit of an increase, but nothing that would be dramatic,” she addd.
Going forward, the question will not only be whether similar spikes continue to occur around the country, but how severe they are.
Discerning where the contagion began
Observing an uptick in cases is only the first step towards addressing an outbreak.
What’s important, Hassig said, is being able to determine how it began. That can become a telling indicator of how many people may have initially been exposed, and add to our understand of how the disease spreads.
The protests have sparked questions about whether they will serve as vectors for future outbreaks. NBC news reported on Tuesday that an unspecified number members of Washington, D.C.’s National Guard had tested positive for the virus.
“It’s going to be a complicated analysis to really discern the various factors at play here, because in many locations you have both things occurring at the same time: protests and also reopening,” Josh Michaud, Associate Director for Global Health at the Kaiser Family Foundation told TPM.
He added that tracking the illness by who comes down with it could help give clues about how an outbreak began.
“If you see an increase in cases among prisoners, nursing homes, two weeks after protests, it’s unlikely that those populations participated,” Michaud said. “But it’s going to be difficult to get really good data on this, and it may be that there’s so much intermingling of these two factors that it may be nearly impossible to determine.”
How quickly can we contact trace?
The time it takes to track the origin of an outbreak is a major factor in determining how bad an outbreak may be.
Contact tracers will need to track the contacts of infected people until they can reach the index case: the first person to contract the disease in a given outbreak.
“The longer it takes for you to get to that index case and the folks they’ve exposed, and then reach out to those people and get them into quarantine, the more time there is for that transmission to go on and to infect additional people,” Dr. Lamar Hasbrouck, a former CDC epidemiologist and former Director of the Illinois Department of Health, told TPM. “Its a matter of, can you quell the transmission or will you let it run out of control like a wildfire.”
New York City is in the process of hiring 2,500 contact tracers in an effort to pin down the history and social interactions of people recently infected.
The longer it takes for contact tracers to do that, the more likely it is that people who may have been infected will spread the disease to others.
“The concern is that we’re potentially launching an unknown number of infection chains that will progress through whatever connections and networks those individuals have in work and their social lives,” Hassig said, adding that “it might be a couple of cycles of infection” before the contacts of infected people are fully traced.
Capacity
With the country reopening, increased infection rates only tell half of the story.
The other half has to do with capacity in terms of hospital beds and ICU rooms.
In Arizona, for example, cases have been increasing steadily, to the point where the state’s health-care system is beginning to sound the alarm.
Last week, the CEO of Banner Health, a hospital chain with a large presence in Arizona, said that the system’s ICU beds were nearing capacity.
Hasbrouck pointed out that increased testing in recent weeks has yielded more cases that were already out there, but few localized instances where hospitals have been overwhelmed.
“We know 80–90 percent of folks that have the disease never make into the ICU because their symptoms are mild enough to mange,” Hasbrouck said, adding that looking at the case count combined with local ICU bed and ventilator usage provides a more accurate way of seeing the stress that the disease is placing on the system.
The words we use
The biggest factor, epidemiologists said, is national messaging, and the extent to which it is in line with data.
With incorrect messaging and incomplete data, even the best-intentioned public health responses are likely to founder.
“What concerns me is probably the deemphasis on the precautions that need to continue even though we’re reopening,” Hasbrouck said. “We don’t want the public to think that because we’re opening up, everything is okay.”
“It’s horrible. It’s lethal,” said Gary Slutkin, a former WHO epidemiologist. “If you start to believe that things are fine and not really a problem here, you’re less likely to be wearing a mask and social distancing, so it’s catastrophic for the right public health practice.”
To Slutkin, the country’s plan for handling the pandemic has been ill-conceived on a fundamental level for months.
“Opening up is the wrong goal,” Slutkin argued, adding that the government had made several mistakes in its messaging. “When you’re really working an epidemic correctly, the goal is stopping its spread and having very few cases.”
The first was setting “flattening the curve” as a final goal, while it really marks a midpoint in the handling of a pandemic.
“Celebrating bending the curve is celebrating where you are at halftime — you have not finished,” Slutkin said. “You have gotten to a halfway point at best, and if you just stay there, you may stay with that number of deaths and don’t drop, so you continue to have infections spread, disease, and death.
