How the numbers have changed since March 31, 2020. Sources: Johns Hopkins COVID-19 Interactive Map and the Maine CDC. (Bear in mind that I am writing this at 9:00 am EDT.)

  • Number of confirmed cases of COVID-19 around the world: Was 801,400 and is at this moment 1,362,936
  • Number of confirmed cases of COVID-19 in the United States: Was 164,610 and is at this moment 368,449
  • Number of confirmed cases of COVID-19 in Maine: Was 275 and is at this moment 499

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 Dr. 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. Thank you, Dr. Mills.

Not-So-Brief COVID-19 Update. April 6, 8:30 AM

I don’t always get a chance to watch the news on the pandemic, but when I do, it sometimes shows me what a bubble I seem to be in. For instance, the headline a couple of days ago was how Maine saw the largest one-day increase in cases. I thought, “well, of course”. Infectious disease epidemics with the biostatistical characteristics of COVID-19 (and known about since January) grow exponentially, which by definition means we expect each day’s increase to, on average, be larger than the prior day’s increase until the infection cannot spread further.

Stopping the spread and teachable moments

The choices for stopping the infection’s exponential spread include: the population becomes immune because of vaccine (12-18 months away); the population becomes immune because the vast majority of people have contracted the infection and recovered (not an option with this virus, given there is no treatment and given the relatively high hospitalization and fatality rates); we keep away from each other as much as is humanely possible and quarantine and isolate anyone who has been exposed or who has the symptoms. The latter option — also known as non-pharmaceutical interventions (NPIs) or social distancing combined with respiratory hygiene — is the main option available to us. And really the only one.

After working in the office every day for several weeks, I worked from home over the weekend. The experience also showed me a different kind of bubble I seem to be living and working in. In my driving back and forth to the office and my once-weekly 7 AM trip to the grocery store, I see almost no one, and since I live in Portland, I assume that means most everyone is complying with the executive orders issued by Maine and the City. Without divulging anyone’s identity and going into too many details, I was sorry to learn about a younger neighbor (not anyone I know) who allegedly hosted a small gathering of mostly family members, including with an out of state guest who was visiting for the weekend. I live in a condo complex with a fair number of older people at high risk for severe disease, so this behavior was especially concerning. It appeared the neighbor was unaware of the new executive orders. With some intervention, it was hopefully a teachable moment for the neighbor. And it did raise the issue of how to communicate these orders during a time when many younger people do not read the newspaper or listen to the tv or radio news. Fortunately, the condo association has a text messaging service, so a message went out to all condo owners this weekend, alerting them to the executive orders and the reasons for them, and strongly encouraging everyone to abide by them.

It may seem to some like an incident that is okay to ignore and “mind one’s business”, after all, it was only one incident. However, one major challenge with social distancing strategies and COVID-19 is that the infection naturally spreads through a non-immune population exponentially, with an infected person typically infecting three others, and those three others infecting three more, etc. Social distancing strategies can likewise have an exponential impact in the opposite direction, reducing transmission from an average of three other people per infected person to less than one (that’s the goal), and breaking the exponential chain of transmission. But one break in social distancing can cause the disease to rise exponentially again.

In other words, social distancing is also a social contract that counts on everyone participating to the extent possible. It only takes one asymptomatic person spreading the disease for it to take off again. And unfortunately, we keep learning how common asymptomatic spread is with COVID-19. The good news is that even essential businesses in Maine are required to take precautions to minimize the chances of virus transmission. But we all need to do our part, and the same precautions essential businesses are taking – e.g. maintaining 6’ distancing as much as possible, providing plexiglass shields (e.g. for cashiers), and sometimes masking – are impossible to do in a social gathering in a small condo. If we care for our health, the health of our neighbors and people who must work in essential businesses, and the health of our communities, then it is our business to make sure we are all practicing social distancing.

Glimmers of hope

Although Maine is seeing the expected exponential increases in COVID-19 cases, there are some glimmers of hope. For instance, the doubling time of the numbers of cases seems to be about seven days, which is much higher than two to three days seen only three weeks ago and is higher than the five days seen nationally. This is an indicator that the social distancing may be flattening the curve.

Maine’s very preliminary hospitalization rate of 6.2 per 100,000 seems a third higher than the national rate of 4.6 per 100,000. However, given that hospitalizations for COVID are much higher among those 65 and older, it may be that Maine’s high median age (45 versus 38 nationally) and high proportion of people 65 and older (21% versus 16% nationally) are contributing to an overall higher hospitalization rate.

Every week that goes by we have more data and are learning more about this disease in Maine as well as in the U.S., and what is working and not working. Even in countries such as Japan that seemed to be doing well early on, recent surges in the pandemic and new government mandates are reminding us that COVID-19 is not skipping over countries.

The peak and life on the other side

But what does the peak look like? No one really knows, and certainly, all eyes are on China and Italy as they start to reopen. One observation is that in places like Maine, where population density is not too high (43 per square mile, versus 70,000 in New York City) and where social distancing mandates were implemented very early on, the peak may not spike as tall and steeply as it is in New York and Italy. This flattening the curve is the goal, as it means fewer deaths and a functioning healthcare system. While we fully expect a surge, it may take longer to get here (giving us more time to prepare), the surge may be spread out over time, and it may not go down as rapidly. In other words, the same number of people could get sick with COVID-19, but over a longer period of time, and ultimately more people have a chance of surviving. With social distancing, it is also hoped that many fewer people ultimately get sick with COVID-19.

What does life look like on the other side of the peak? To answer this question, there are several factors we don’t know yet. We don’t know how much the virus will continue to circulate among the population. Some viruses, like influenza, lose steam over the summer, only to roar back in the fall and winter. We also don’t know how many people will be immune. How many are silently contracting the infection and becoming immune? And we don’t know how long immunity lasts and if the virus will be changing much, making long term immunity challenging, such as the case with influenza.

What is likely is continued widespread social distancing mandates for several weeks to suppress the epidemic, as what is being done now. Then, as the epidemic loosens its grip and we have learned a great deal more about who is really at risk for severe disease, there will need to be ongoing mitigation strategies until there is a vaccine widely available.

What do these mitigation strategies look like? They could include: widespread rapid testing among those who are symptomatic and/or those in high-risk settings such as nursing homes; contact tracing and isolation, e.g. isolating those who test positive and their close contacts; keeping those at high-risk physically isolated. Hopefully, after the surge is past peak – in the coming weeks – schools and businesses can reopen, and strong mitigation strategies can go into place. But to keep those at risk safe, social distancing should stay in place to one degree or another, such as bans on large crowded gatherings, especially those that include older people and others at risk. Meanwhile, we will continue to learn a great deal from China, Europe, and states that are ahead of us on the epidemic curve. Those lessons will inform our own strategies.

Although we may be almost at the worst of it, it’s clear that until there is widespread immunity – enough to provide herd immunity – our lives are unlikely to return to normal anytime soon. It is indeed a marathon, a long-lasting blizzard. However, as we get through this surge and emerge on the other side, we will know a lot more and be able to determine the activities that can return to normal, even as the threat of additional surges continues until there is sufficient immunity in the population.

Daydreaming bubble

I sometimes find myself in the bubble of daydreaming. Maybe there will be a treatment that emerges. Knowing that such a panacea is unlikely, I more often dream instead of the day we have a vaccine available to us. I tear up thinking of the joy of seeing health care workers, first responders, nursing home residents, grocery store baggers, older people and those with chronic conditions lined up to get vaccinated. This must have been what it was like in 1955 when millions of children lined up to get the polio vaccine and were then able to have fun at the beaches without worrying about contracting the deadly disease. And on that day when vaccine against COVID-19 is widely available, we can return to family gatherings, graduations, and normal grocery shopping. I love daydreaming in this bubble. It will help get us through these next several weeks.

Dora Anne Mills, MD, MPH, FAAP

Additional information

Podcast of Dr. Mills’ updates

Dr. Mills’ daughter started a podcast where she has been reading her mother’s updates. Here’s the link to the latest update. You’ll find the previous ones there as well.