Canadians being urged to help 'flatten the curve' of COVID-19
Goal is to slow the spread of the virus in order to reduce the load on the country's health-care system
A COVID-19 information letter is shown at a coronavirus evaluation clinic in Montreal on Tuesday. Experts say the key is to now slow the spread of the virus in Canada and 'flatten the curve,' which refers to an epidemiological graph of a disease outbreak.
The dispatches from the front lines of the COVID-19 outbreak in northern Italy are chilling.
"Nurses with tears in their eyes because we can't save everyone … Every ventilator becomes like gold."
That was the message last week from Dr. Daniele Macchini, an Italian physician whose lengthy Facebook post was published in a local newspaper, translated into English and circulated on social media.
"And there are no more surgeons, urologists, orthopedists; we are only doctors who suddenly become part of a single team to face this tsunami that has overwhelmed us," he wrote.
Three professors from the University of Milan also sent a letter warning doctors in the rest of Europe to "get ready," because 10 per cent of patients who test positive for COVID-19 end up needing intensive care.
"This situation is like a bomb that explodes, and you're simply overwhelmed by an incredible number of patients," another Italian physician, Dr. Giacomo Grasselli, told the CBC News Network this week.
Grasselli is co-ordinating the intensive care response in Milan, the largest city in the country's hard-hit northern region. All of Italy's 60 million people are now under a sweeping lockdown, subject to travel and social restrictions aimed at curbing the spread of Europe's worst outbreak of coronavirus.
"We're living this now," said Grasselli. "My mission is not only to take care of Italian patients, but also to tell other people in the world how to get ready for this."
There's still time to 'flatten the curve'
Canada still has time to avoid such a situation, experts say.
As the global number of coronavirus cases nears 120,000 people in 115 countries, chances of stopping its spread are now considered unlikely. So public health officials have turned their attention to slowing it down.
And the key is to "flatten the curve" — a reference to an epidemiological graph of a disease outbreak.
A large spike on that graph, representing a sudden increase in people with infections, can be catastrophic even for health-care systems in highly developed countries like Canada.
This graph demonstrates the impact public health measures can have in 'flattening' the curve of a disease, slowing down virus transmission and easing pressure on the health-care system.
"If you can slow it down enough and flatten the curve, so the same number of people get infected, but over a much longer period of time, then ... what you're allowing is that the capacity will not be exceeded," said Dr. Anand Kumar, a critical care physician at Winnipeg's Health Science Centre.
"And that protects the community, so that an ICU [i.e. intensive care unit] bed will be available when it's needed."
Most healthy people will experience a mild COVID-19 infection because their immune system will protect them. But so far, the experience in Italy and China suggests that as many as 10 per cent of people infected can require critical care.
That creates an urgent need for beds in intensive care units, along with ventilation, dialysis and other life support technology. It also requires qualified health-care specialists to manage patients — excess capacity that Canadian hospitals just don't have.
Most of the country's hospitals are already operating at 100 per cent capacity, a largely normal situation in Canada's health-care system.
"We've got a system that is designed to meet what our usual demands are," said Dr. Robert Fowler, a critical care physician at Toronto's Sunnybrook Hospital. "We're at capacity most of the time."
Add to that the extra load from this year's bad flu season, and suddenly, even in Canada, there's a risk that care might not be available when patients need it.
"Ideally, you prevent people from being infected — but you certainly don't want to have everybody infected at once," said Fowler. "We don't want to overwhelm the system."
But the Italians warn that could happen.
"If you do not stop the spread of the disease, your health system — no matter how good, how efficient, how modern it is — sooner or later will collapse," said Grasselli. "Because the number of patients is too high for the resources we have everywhere in the world."
That's why in Canada (and elsewhere) large events are being cancelled, some people are being told to work from home, and some students will be taking courses online for a few weeks. It's a temporary public health strategy aimed at slowing the potential spread and buying time.
"That's what people are trying to do to try to prevent the spread right now so we don't get overwhelmed," said Fowler. "And it's going to very much depend on how effective we are at preventing transmission in the community."
Dr. Anand Kumar is a critical care physician at Winnipeg's Health Sciences Centre. He said 'flattening the curve' of COVID-19 infections in Canada will ensure that critical care beds are available for everyone who needs one.
Another complicating factor is the fact that there is no vaccine and there are no drugs to treat COVID-19.
"In this particular circumstance, we're not going to have a vaccine for at least a year, if not a year-and-a-half," said Kumar. "And there's no known antiviral drug for coronavirus, so essentially all we can offer is supportive care.
"If you get mildly ill, there's not something we can give you to stop you from getting severely ill. So what's going to happen is going to happen. And we're just going to have to try to support patients as best we can."
The importance of beds, ventilators
Fowler led a team of researchers that conducted a survey of Canada's critical-care capacity after the 2009 H1N1 epidemic. At the time, there were about 3,200 ICU beds and almost 5,000 mechanical ventilators spread out in 286 hospitals across Canada.
Ventilators are mechanical breathing machines that will be critical for COVID-19 patients whose lungs are so badly damaged they have trouble getting enough oxygen.
The survey concluded that intensive care resources vary widely across Canada and "during times of increased demand, may result in geographic differences in the ability to care for critically ill patients."
[The Canadian province of] Ontario, for example, had an extra 209 ventilators stockpiled and spread out across the province as of last August, according to one provincial document.
Canada's hospitals are counting their ventilators, used to assist breathing in critically ill patients. Experts warn that Canadian hospitals have limited space and capacity. That's why slowing the spread of COVID-19 is important to preserve that capacity.
"The physical space within a hospital to care for people is, I think, probably even more challenging beyond the physical number of ventilators," said Fowler.
Kumar is particularly concerned about the number of qualified staff to handle a possible surge in patients.
"The bottleneck is in manpower, even more than physical space and even ventilators," he said. "I think everybody is contingency planning for the possibilities."
Some of the challenges now relate to approaching the management of COVID-19 on a national scale — and being ready to help regions that are hit harder, experts say. That may involve moving equipment and health-care workers to where they are most urgently needed.
"There's patchiness in where these outbreaks hit," said Fowler. That means doctors and nurses can be completely overwhelmed in one place, but it can be business as usual in the rest of the country.
In Italy, health-care workers are already talking about the grim reality of "triaging" under strained circumstances, which means they're being forced to choose between life and what might have been a preventable death for some people, based on the availability of ventilators and ICU beds.
Canada has studied the concept of such triaging, but Fowler said so far no system has been established.
"In Canada, we don't really have a working example of what that would look like and we haven't had to do that," he said.
"We shouldn';t be having that conversation ahead of the conversation about when a place gets busy, how can we bring support."
More information: Why 'Exponential Growth' Is So Scary For The COVID-19 Coronavirus. (OP: Includes data on how growth in cases in the U.S. currently is currently exponential.)
OP: Information on other major pandemics in human history follows.
(1) How the Horrific 1918 Flu Spread Across America. (OP: Article published in 2017.)
The toll of history’s worst epidemic surpasses all the military deaths in World War I and World War II combined. And it may have begun in the United States.
Haskell County, Kansas, lies in the southwest corner of the state, near Oklahoma and Colorado. In 1918 sod houses were still common, barely distinguishable from the treeless, dry prairie they were dug out of. It had been cattle country—a now bankrupt ranch once handled 30,000 head—but Haskell farmers also raised hogs, which is one possible clue to the origin of the crisis that would terrorize the world that year. Another clue is that the county sits on a major migratory flyway for 17 bird species, including sand hill cranes and mallards. Scientists today understand that bird influenza viruses, like human influenza viruses, can also infect hogs, and when a bird virus and a human virus infect the same pig cell, their different genes can be shuffled and exchanged like playing cards, resulting in a new, perhaps especially lethal, virus.
We cannot say for certain that that happened in 1918 in Haskell County, but we do know that an influenza outbreak struck in January, an outbreak so severe that, although influenza was not then a “reportable” disease, a local physician named Loring Miner—a large and imposing man, gruff, a player in local politics, who became a doctor before the acceptance of the germ theory of disease but whose intellectual curiosity had kept him abreast of scientific developments—went to the trouble of alerting the U.S. Public Health Service. The report itself no longer exists, but it stands as the first recorded notice anywhere in the world of unusual influenza activity that year. The local newspaper, the Santa Fe Monitor, confirms that something odd was happening around that time: “Mrs. Eva Van Alstine is sick with pneumonia...Ralph Lindeman is still quite sick...Homer Moody has been reported quite sick...Pete Hesser’s three children have pneumonia ...Mrs J.S. Cox is very weak yet...Ralph Mc-Connell has been quite sick this week...Mertin, the young son of Ernest Elliot, is sick with pneumonia,...Most everybody over the country is having lagrippe or pneumonia.”
Several Haskell men who had been exposed to influenza went to Camp Funston, in central Kansas. Days later, on March 4, the first soldier known to have influenza reported ill. The huge Army base was training men for combat in World War I, and within two weeks 1,100 soldiers were admitted to the hospital, with thousands more sick in barracks. Thirty-eight died. Then, infected soldiers likely carried influenza from Funston to other Army camps in the States—24 of 36 large camps had outbreaks—sickening tens of thousands, before carrying the disease overseas. Meanwhile, the disease spread into U.S. civilian communities.
The influenza virus mutates rapidly, changing enough that the human immune system has difficulty recognizing and attacking it even from one season to the next. A pandemic occurs when an entirely new and virulent influenza virus, which the immune system has not previously seen, enters the population and spreads worldwide. Ordinary seasonal influenza viruses normally bind only to cells in the upper respiratory tract—the nose and throat—which is why they transmit easily. The 1918 pandemic virus infected cells in the upper respiratory tract, transmitting easily, but also deep in the lungs, damaging tissue and often leading to viral as well as bacterial pneumonias.
(OP note: The difference between seasonal flu and pandemic influenza may lie in the difference between 'antigenic drift' and 'antigenic shift'.)
Although some researchers argue that the 1918 pandemic began elsewhere, in France in 1916 or China and Vietnam in 1917, many other studies indicate a U.S. origin. The Australian immunologist and Nobel laureate Macfarlane Burnet, who spent most of his career studying influenza, concluded the evidence was “strongly suggestive” that the disease started in the United States and spread to France with “the arrival of American troops.” Camp Funston had long been considered as the site where the pandemic started until my historical research, published in 2004, pointed to an earlier outbreak in Haskell County.
Wherever it began, the pandemic lasted just 15 months but was the deadliest disease outbreak in human history, killing between 50 million and 100 million people worldwide, according to the most widely cited analysis. An exact global number is unlikely ever to be determined, given the lack of suitable records in much of the world at that time. But it’s clear the pandemic killed more people in a year than AIDS has killed in 40 years, more than the bubonic plague killed in a century.
The impact of the pandemic on the United States is sobering to contemplate: Some 670,000 Americans died.
In 1918, medicine had barely become modern; some scientists still believed “miasma” accounted for influenza’s spread. With medicine’s advances since then, laypeople have become rather complacent about influenza. Today we worry about Ebola or Zika or MERS or other exotic pathogens, not a disease often confused with the common cold. This is a mistake.
We are arguably as vulnerable—or more vulnerable—to another pandemic as we were in 1918. Today top public health experts routinely rank influenza as potentially the most dangerous “emerging” health threat we face. Earlier this year, upon leaving his post as head of the Centers for Disease Control and Prevention, Tom Frieden was asked what scared him the most, what kept him up at night. “The biggest concern is always for an influenza pandemic...[It] really is the worst-case scenario.” So the tragic events of 100 years ago have a surprising urgency—especially since the most crucial lessons to be learned from the disaster have yet to be absorbed.
(OP: The rest of this fascinating article is here.)
(2) OP: One of the most deadly epidemics ever was in the Middle Ages. Plague has a huge death rate (i.e. case fatality rate, defined as the proportion of reported cases of a specified disease or condition which are fatal within a specified time, is incredibly high (i.e. 30% to 100% with no medical treatment). Plague is caused by Yersinia pestis (=a type of bacteria).
The Black Death: The Greatest Catastrophe Ever
Ole J. Benedictow describes how he calculated that the Black Death killed 50 million people in the 14th century, or 60 per cent of Europe’s entire population.
The disastrous mortal disease known as the Black Death spread across Europe in the years 1346-53. The frightening name, however, only came several centuries after its visitation (and was probably a mistranslation of the Latin word ‘atra’ meaning both ‘terrible’ and ‘black)’. Chronicles and letters from the time describe the terror wrought by the illness. In Florence, the great Renaissance poet Petrarch was sure that they would not be believed: ‘O happy posterity, who will not experience such abysmal woe and will look upon our testimony as a fable.’ A Florentine chronicler relates that,
All the citizens did little else except to carry dead bodies to be buried [...] At every church they dug deep pits down to the water-table; and thus those who were poor who died during the night were bundled up quickly and thrown into the pit. In the morning when a large number of bodies were found in the pit, they took some earth and shovelled it down on top of them; and later others were placed on top of them and then another layer of earth, just as one makes lasagne with layers of pasta and cheese.
The accounts are remarkably similar. The chronicler Agnolo di Tura ‘the Fat’ relates from his Tuscan home town that
... in many places in Siena great pits were dug and piled deep with the multitude of dead [...] And there were also those who were so sparsely covered with earth that the dogs dragged them forth and devoured many bodies throughout the city.
The tragedy was extraordinary. In the course of just a few months, 60 per cent of Florence’s population died from the plague, and probably the same proportion in Siena. In addition to the bald statistics, we come across profound personal tragedies: Petrarch lost to the Black Death his beloved Laura to whom he wrote his famous love poems; Di Tura tells us that ‘I [...] buried my five children with my own hands’. (Source.)
Origin And Incidence
Having originated in China and Inner Asia, the Black Death decimated the army of the Kipchak khan Janibeg while he was besieging the Genoese trading port of Kaffa (now Feodosiya) in Crimea (1347). With his forces disintegrating, Janibeg catapulted plague-infested corpses into the town in an effort to infect his enemies. (...)
Second pandemic of the Black Death in Europe.
The second pandemic of the Black Death in Europe (1347–51).
There were recurrences of the plague in 1361–63, 1369–71, 1374–75, 1390, and 1400. (Source)
(OP: More on plague and Yersinia pestis (including its continuing presence in the world today) is here.)