It’s been one week since I shared an update from Dr. Dora Anne Mills on COVID-19 in Maine.

Here’s how the numbers have changed since March 10, 2020.

  • Number of confirmed cases of COVID-19 around the world: Was 116,152 and is at this moment 183,372.
  • Number of confirmed cases of COVID-19 in the United States: Was 761 and is at this moment 4661.
  • Number of confirmed caes of COVID-19 in Maine: Was 0 and is at this moment 17.

What do the numbers mean? What’s being done here in Maine to help “flatten the curve”? What can we do as individuals? Lots of questions and one of the people I trust for answers is Dora Anne Mills. She was the director of the Maine CDC and the State’s Health Officer for 14 years. She is currently the Chief Health Improvement Officer for MaineHealth.

Dr. Mills has been sharing information about COVID-19 on her Facebook page. She calls them Not-So-Brief COVID-19 Updates. Because not everyone is on Facebook or has access to the information, with her permission, I will be sharing some of them on the Catching Health blog. This is her latest update.

Not-So-Brief COVID-19 Update. March 17, 7 AM.

Novel coronavirus has spread fairly rapidly here in Maine the last two days. While the actual numbers may not seem impressive – the official count yesterday morning being 17 – there are concerning but also not completely unexpected trends.

First, there is increasing evidence of community spread in the Portland area, as more cases accumulate who do not have a known exposure history (e.g. travel to an area with an identified outbreak or exposure to someone with diagnosed COVID-19). That usually means the case counts are the tip of the iceberg, and the actual number of people with infection is several times higher.

Second, the numbers of people testing positive have expanded into some other counties up the coast – Knox and Lincoln counties.

Third, several health care workers have tested positive. As a result, two outpatient facilities have closed for two weeks because so many of the staff were exposed. One is a public health clinic that serves those who are homeless or have underlying conditions such as TB, AIDS, or drug addiction, and the other is an oncology practice.

Besides being concerned about how to care for these clinics’ patients and the possibility of exposure to COVID-19 of these vulnerable patient populations, these two examples show the deep impact and strain on the healthcare system that even two infections among health care workers can have. This is why it is critical we focus on two healthcare goals – to care for patients and to ensure the safety of healthcare workers (including first responders) – as well as to focus on the broader public health goal of preventing the spread of the epidemic.

Fourth, one person who tested positive lives in a senior living facility. We know from Washington State and some other locations that such facilities are at risk for major outbreaks. So, while the numbers in Maine may not seem too impressive, the stories behind them should cause all of us to pause.

With that said, the overall numbers are also a concern. Early epidemiology studies of COVID-19 in China indicate we can expect to see case numbers doubling every six days. More recently, the doubling times seen in Europe and the U.S. have been between two and four days. With 17 known to be infected in Maine, a doubling time of six days could mean that in 24 days 272 Mainers could have COVID-19. With a doubling time of three days (closer to what is actually occurring in the U.S.), that means 4,352 Mainers – without interventions – could have COVID-19 in 24 days. These numbers could be much higher, since we don’t really know how many in Maine currently have COVID-19, given that some early cases indicate community spread in Greater Portland and given that the Maine CDC and NorDx labs were just able to start testing last week. BUT, and this is a critical point – the numbers could be much lower, depending on our individual and collective actions we take now.

Clearly we are on the steep uphill slope of the epidemic curve, which, if unchecked, rises exponentially until most of the population gains immunity. This is the epidemic curve that everyone wants to flatten. It is the one that we absolutely must flatten. We had warnings from China, then South Korea, and now Italy and most of Europe.

The good news is that with at least one case identified on Sunday indicating community transmission, rapid action has taken place the last two days. After taking action last week with the identification of the first person testing positive (e.g. recommending all indoor gatherings of 250 or more be postponed and other actions), Dr. Nirav Shah, Maine CDC director, and Governor Mills (full disclosure, she’s my sister) held a rare Sunday evening press conference to announce increasingly aggressive actions, including declaring a civil state of emergency and recommending that all schools close, healthcare postpone elective surgeries and visits, long term care facilities restrict visitors, all events with 50 or more people be postponed, and that all gatherings of more than 10 people that include individuals who are at higher risk for severe illness, such as seniors, be postponed until further notice.

The City of Portland on Monday announced an emergency curfew, including that all establishments where groups gather must close all day Tuesday as well as after 8 pm for the rest of the week. Since St. Patrick’s Day is usually a major holiday here in this community with a strong Irish heritage and known for its restaurants and breweries, this curfew was a somber but wise step to help stem the tide of COVID-19.

Additionally, President Trump declared that over the next 15 days Americans should not gather in groups of more than 10 people, schooling should be at home, and discretionary travel and social visits should be avoided. He also stated that if anyone in a household tests positive for the virus, everyone who lives there should stay home.

All of these actions are taken in order to increase the doubling time, i.e. slow the spread or “flatten the curve”, and to preserve the healthcare system. Social distancing strategies were not implemented during this most critical phase of early exponential growth of the epidemic in Italy, Iran, and Hubei Province in China, and that is one reason why the epidemic has been so catastrophic there. But this early phase, in which these strategies can work, is a narrow window because of the exponential growth and a short doubling time, especially when there is already community transmission, as is the case in Portland.

Other social distancing strategies include sheltering-in-place, which is now in effect in San Francisco and means that everyone is asked to stay at home, as we do in a blizzard. And to clarify two other terms one commonly hears these days: quarantine is when someone who has been exposed to an infected person but is not yet symptomatic is kept separated from others, most often in their own home. Isolation involves separating someone who is infected or symptomatic from others. Sometimes quarantine is also considered a form of isolation.

Although I wrote the other day on the pros and cons of school closure, with community spread and a short doubling time currently seen in the U.S. (2.4 days), it seems like a prudent move. We will only know afterward whether the benefits outweigh the risks. However, we do need to address some very time sensitive and critical issues, such as: how to feed children who are dependent on schools for food; and how to provide child care for health care workers, first responders, and other employees essential for public health and safety. Addressing the food needs of children and the child care needs of essential workers often means bringing groups of children and adults together, but as long as other social distancing and vigilant respiratory hygiene strategies are implemented, the benefits likely outweigh the risks.

I feel the most important point I can make today is that although our governments have taken swift and aggressive actions the last two days – the City of Portland, the State of Maine, and the U.S. federal government – those actions are only as effective as we the people take responsibility. This is the time. We are in a very narrow window that our individual and collective actions can make a big difference. And only a few infected people spreading the disease can cause havoc – i.e. cause the epidemic curve to spike. This is especially true as we increasingly understand there may be significant spread among those who are not yet symptomatic.

What should we do? Except for your household members who have not been exposed to COVID-19 or who are not sick, keep at least six feet from everyone else. At MaineHealth’s corporate headquarters, for a critical meeting yesterday, we sat in a room, each at a separate table, keeping us at least 6 feet apart. Other meetings are held by phone or using video technologies. And we need to remain very vigilant with respiratory hygiene.

If you are able to work from home, then do so. If you are in higher risk category (>50, but especially >70, or have a chronic serious medical condition), then you need to stay away from others as much as possible, and yes, including staying away from grandchildren.

If you run an organization or business, what should you do? There are many factors to consider, including: how critical are the services you provide; what is the risk profile of the people you serve as well as that of your workforce (e.g. do you have many older people who work for you or whom you serve); can you use distant technologies or other distancing strategies to provide your services (e.g. for restaurants, home delivery or take out)? Besides considering these factors, the situation may change, since if COVID-19 continues to spread exponentially, governments may have to take more drastic measures (such as closing businesses and ordering sheltering-in-place as has occurred in several European countries).

Even on Saturday, when we only had six who had tested positive in Maine, the impact on people’s lives was so evident. In my urgent pursuit to replace a broken phone, I encountered a young salesman at the store who shared that his fiancé just lost her job, as the restaurant where she works closed for the duration of the pandemic. He was expecting to be laid off soon, since they had received word his store would also be closing. He said the local Apple store had already closed. We are fortunate that so many businesses can now allow workers to telecommute. But retail stores, restaurants, movie theaters and many others cannot.

As we discuss the number of “cases” of COVID-19, as Dr. Nirav Shah so well pointed out at Sunday evening’s press conference, there are people and families behind each of these cases. I would add that there are many more “cases” than those who test positive: there are those who are infected who are not tested; students who are at home wondering where their next meal will be; workers who have lost their jobs; and families who are having to close their businesses. Although I feel heartened that all levels of government seem to be trying to address all of these “cases”, it is clear that it will take all of us working together to assure the safety and overall health of our communities.

On this St. Patrick’s Day, I’ll be donning some green and a shamrock brooch of my mother’s. My hope is that just as we normally come together for this holiday, that we instead come together in the spirit of the Irish – to support each other, to call friends, to email a message to loved ones, and to ensure that social distancing is not social isolation. Indeed, we may be separate, but it is together in spirit how we will get through this challenging time.

Dora Anne Mills, MD, MPH, FAAP