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COVID-19 Pandemic: Natural Solution

HERD IMMUNITY: Natural Solution for COVID-19 Pandemic

This past week the COVID-19 Response Team at the Imperial College London, published a critical report, “Impact of Non-Pharmaceutical Interventions (NPIs) to Reduce COVID-19 Mortality and Healthcare Demand.”, they ran computer simulations to project the effectiveness of NPIs (social distancing, isolation, quarantine, and lock-down of public venues and workplaces) in diminishing and containing COVID-19 in the short-term as well as into the months ahead when, for practical reasons, such interventions would need to be relaxed or stopped.

Suppression: The goal is cessation of new disease, stopping it.

Mitigation: The goal is blunting the exponential trajectory of new cases such that the straight-up curve is bent horizontally, ultimately downward toward no new cases. Mitigation is controlled occurrence of new cases to try to match case volume to healthcare resources, such as general hospital and ICU beds and staffing to achieve optimal survival numbers. The goal is management of the epidemic to spread it out over time, but not immediately ending it.

Both approaches have their problems. All out suppression may kill the epidemic, but also the “economic and societal patient” with the cure. If it continues for more than a couple weeks, the damage to people’s lives may be devastating and irreversible , for at least a long foreseeable future. COVID-19 causes literal death in probably 1% of cases (this figure subject to change with broader virus testing). However, the loss of a business, a home, retirement savings, a career path, and so on, is a virtual or figurative death. Furthermore, such disruption or even destruction of our American societal model is a national security matter. If a substantial segment of the tax base (the middle-class) is out of work and now financial entitlement dependent, there is no revenue coming into the treasury to support the military, Social Security, Medicare… you get it.

Looking over these data, I have reached a conclusion. A number of facts support it as the solution to this pandemic, which I will detail further on. The solution is a new goal- deliberate herd immunity. This goal embraces suppression and mitigation strategies in a hybrid model, and uses NPIs in a timed way to preserve the foundations of our economy and society while managing the ongoing contagion.

In a word, the concept of deliberate herd immunity is to use SARS-CoV-2 virus as the vaccine. Use the virus against itself. Our problem (as is, by definition, the case with pandemics) is this is a “novel” virus- one to which the human race had not been previously exposed. So, there is no immunity worldwide to it. Once we get through this initial epidemic, it will no longer be “novel”. Most will have survived (about 99%, by current figures), and, though there will likely be future uprisings of SARS-CoV-2 again, those events should be more like seasonal influenza outbreaks.

So, the premise is simple, but somewhat counter-intuitive. What I am suggesting is that, in a deliberately constructed plan, we run toward SARS-CoV-2. Embrace it so that it passages through the majority of our low-risk population while they are at school, at work, conducting their lives. Once a majority of the society is immunized (the “herd”), the virus has very few places to go and so the risk of the virus to the high-risk minority is less. If 70% of 238 million Americans are infected (Germany recently estimated that number for its country), a 1% mortality rate translates into 1.65- 2.2 million deaths; 1.65 million directly from the virus, the rest from non-COVID-19 collateral damage deaths.

But, if you can immunize with the virus the 84% of the population under 65 yrs-old, then the remainder is 52 million people; 1% of that group infected is 520,000 deaths (compared to 1.65-2.2 million). DHI would be effective.

And, the answer is in front of us. Let nature take its course. Run toward the virus in a planned and tightly controlled way.

Mitigation can never completely protect those at high-risk from severe disease or death, but many of those would likely have succumbed anyway. You are trading off that reality for a preserved social and economic order. It sounds cold, but an apt analogy is war. We have conscripted young men to send off to battle, accepting that many will never return. This is done when the country is at stake. This is no different. This is war.

The Plan

1. Complete Suppression (early in epidemic to decrease chance of healthcare system overload)
– 2 weeks across the society (the incubation period of the virus)
– 4 weeks for those who can sustain it economically

2. Mitigation
– 3-5 months
– Return to school/universities in 2-4 weeks
– Return to work in 2-4 weeks (unless able to substantially work at home)
– Public venues (restaurants, small business, entertainment) open in 2 weeks

3. High-Risk Group Carve Out (65 yrs and older, serious pre-existing medical conditions, and immune-deficient individuals)
– Strict suppression NPI until epidemic gone.
– Organized supportive services to elderly (≥65 yrs old) by family, social services organizations, churches, etc.
– Telemedicine virtual visits with treating physicians
– Pharmacies providing extended prescriptions of maintenance medicines and home delivery service
– Only the elderly with critical jobs, such as healthcare professionals should be exempt.

4. Shut-down of mass transit for the foreseeable future (until a clear change in the new case curve downward), accounting for the risk of social crowding and picking up the virus from contaminated surfaces.

5. Healthcare System Suppression: currently measures to control the virus in even major urban medical center hospitals are cosmetic and inadequate. Taking the temperature on arrival of staff and visitors for entry is worthless. Most people coming to a hospital are feeling well, or likely would not go there. All infections cause fever 1-4 times per 24 hours, each in a short period of time. So, a spot temperature reading has no value as a screen for entry. Yet, both hospitals and immigration officials at airports are doing this; suggesting fundamental ignorance of infections or a deliberate “window-dressing” attempt that something is being done. The government needs to impose strict directives on hospitals as follow,
a. No visitation
b. All hospital professional and support staff screened for SARS-CoV-2 every 2 weeks as a condition for work-fitness (not currently being done);
c. Strict mitigation procedures by all hospital professional staff and support workers, not just those attending infected patients in isolation rooms. Masks, handwashing, social distancing. (not currently being done)
Understand this, the healthcare system, its workers and facilities, is the epicenter for the spread of SARS-CoV-2. These workers currently come to their shifts, physically handle the sickest in our society, and then go home to their families. In the hospitals I have been in recently, the staff are going about their duties with no change in behavior anywhere close to what the general population is doing. It is as though they think there is a special exemption from SARS-CoV-2 once you enter a medical building. I suspect they rely on hospital leadership to adequately supervise infection control measures. The government needs to focus its most intense efforts on providing personal protection equipment and mitigation rules of conduct across the profession, inpatient and outpatient. The healthcare system should be the role model for the broader society. It is where the rubber meets the road in a pandemic.

6. Pregnancy: For now, there is no definitive information on SARS-CoV-2 and a fetus. Until more science is developed, it would be better to practice contraception until the pandemic is behind us.

7. Post-Illness Isolation: 2-4 weeks, with 2 negative tests to assure virus is gone.

Conclusion

This proposal puts a suppression hard brake on contagion, then the mitigation phase carves-out the high-risk groups as a special circumstance, then returns the majority of active, productive people to their lives to pass the virus through the population to self-vaccinate with the virus. If herd immunity becomes widespread and endures, new cases and deaths will decline, probably over 3-6 months. Counting on a vaccine is unreasonable.

Be clear, the deliberate herd immunity premise has risks and unknowns. It is not certain that SARS-CoV-2 infection generates enduring immunity. However, the original SARS virus appeared to have provided immunity for at least 2 years in immune-competent individuals, and it is reasonable to assume it is analogous to COVID-19. Mortality rates below 65 yrs-old appear to be 0.2-1.3%, down to 10yrs-old, below which there have been no deaths after a worldwide total of 375,000 diagnosed cases. And those numbers will come down once we have testing to enumerate all those with modest or no symptoms who have not yet been measured. The death rate in those under 65 yrs-old might approach the 0.1% rate of seasonal flu- a reasonable trade-off for not destroying our country’s economy. Asking the American people, most especially the elderly, to put their lives at risk to save the country is no different than the sacrifice we ask of our young military in wartime, except that those at the most risk from COVID-19 have lived the majority of their lives and are focused on their legacies- their families coming up behind them. And their risk is likely about 1% for death, probably far less than that of a 20 year-old serviceman going to another type of war. I think there would be unanimous concensus by the American people, especially the elderly, that this is the right thing, the way to go.

If enduring herd immunity does not result from the experiment, what have we lost? But, we may have gained our lives and the future of our country.

This approach is a rational process of using the power of information to manage the pandemic, but also to the long-term critical foundations and interests of the country, and so of each of us.

Edward R. Rensimer, MD
Infectious Diseases
Director, International Medicine Center
Houston, TX