Winter is coming: COVID-19 and a rational path forward

Data points to evaluate at your agency as we move into a new phase of COVID-19 response

Winter is coming and we’re seeing a surge in COVID-19 cases across the Unites States (and, frankly, in all parts of the world). What does that mean for patient care, provider care and community impact? Well, to quote Arthur Conan Doyle, it’s easy to be wise after the event. Twelve months from now, we’ll likely know quite a bit about COVID-19 as we’ll have more robust datasets, and access to more information about the disease and associated treatments, how the disease impacts different population segments, and more.

But, we’re here today and the increase in cases is happening now. The good news is we know more than we did even six months ago and can start adjusting and preparing accordingly. Let’s take a look at the rise of COVID-19 in three distinct phases to provide some thoughts about a rational path forward for EMS providers.

In the U.S., the three phases, at the highest level, look like this:

As we progress through the different phases of this pandemic on the march to a viable vaccine, we need to look at the data we have at hand to ensure we are as prepared as we can be to support our communities.
As we progress through the different phases of this pandemic on the march to a viable vaccine, we need to look at the data we have at hand to ensure we are as prepared as we can be to support our communities. (Photo/Star Tribune via MCT)

Phase 1: February-May 2020

The data show that there was a significant lack of testing, we had an extremely high mortality rate, there was early activity on the West Coast with Patient One being located in Snohomish County, and the Northeast (particularly New York City) was overwhelmed. Cases confirmed by testing and deaths rose in tandem.

Phase 2: June-August 2020

This phase was characterized by increased testing and an evolution in testing technology, including PCR testing (the gold standard that is used for both screening and diagnosis), antigen testing (that is used for screening), and antibody testing (that is really a diagnosis and measurement of population immunity). We also saw a greater impact on the Sunbelt states, particularly Texas and Arizona.

Two things led to improved outcomes during this phase:

  1. We witnessed the emergence of evidence-based therapeutics.
  2. Expanded testing allowed healthcare providers and policy makers to make adjustments before healthcare facilities were completely overwhelmed, with the rise in testing preceding the rise in deaths by about 21 days.

Phase 3: Current day

As we’ve entered Phase 3, indicators are that testing is far more widespread than it was in the first two phases. We are also seeing an increased case count (some of which can be attributed to more testing, but some of which is attributed to our surveying of the population and not just symptomatic individuals) – but it appears that the patients are younger with fewer comorbidities. Cases are rising at a rapid rate; however, hospitalizations and deaths are rising slower relative to new cases than occurred in the previous phases.

Using data to prepare for COVID-19 response

So, what does all this mean?

As we progress through the different phases of this pandemic on the march to a viable vaccine, we need to look at the data we have at hand to ensure we are as prepared as we can be to support our communities.

  • Cases. According to official statistics, there are approximately 13.86 million confirmed cases of COVID-19 in the United States. Two things, however, strongly indicate there have likely been more than 30 million cases of COVID-19. How do we get to this number? First, for all infectious diseases, there are always many, many more cases than are confirmed by testing. According to the CDC, over the past several flu seasons, actual infections ranged from 9-45 million – yet only up to 800,000 flu tests were evaluated by the CDC because most cases are diagnosed clinically rather than through testing. This is what we do every year with the flu. Secondly, peer-reviewed research indicates that as of July 2020, approximately 8% of the U.S. population (about 27 million people) had antibodies to the virus that causes COVID-19, and we know there have been many more cases since July.
  • Number of deaths. Unfortunately, there has been debate about the number of deaths associated with COVID-19 in 2020, with arguments ranging from the conspiratorial to the pseudo-scientific. If we look objectively at the math, here’s what we know. Every year, the CDC releases data around the number of deaths that occur each month and year in the United States. For decades, we’ve had a steady population count (between 300-330 million) and steady death count each month (about 60,000 deaths). From March-October of this year, however, we’ve seen excess deaths of nearly 300,000 compared to any other year. The main variable that has changed during this time is COVID-19.
  • Mortality rate. Our initial conversation around mortality rate was based on the number of people that died, divided by the number of positive tests. In other words, it’s a case mortality rate. Following that math, the mortality rate looks to be about 2.7%. That would make COVID-19 about 20 times more lethal than seasonal flu. In reality, we should be comparing infection mortality rate to number of deaths (vs. case mortality rate). In other words, based on the numbers above, we know there are likely 30+ million cases. That brings the mortality rate down to 0.6% – which is still five times deadlier than the flu, but it helps put the numbers (and our associated response to the numbers) in perspective.
  • 911 calls. Here’s where it gets interesting. Based on our data, we’ve actually seen a less severe rise in calls for COVID-19 as well as confirmed hospital diagnosis for COVID-19 compared to previous phases. Cases are rising rapidly while EMS transports are rising more slowly. This means the population that is getting infected likely skews younger, isn’t as impacted by the disease as the folks affected in phase 1, and that treatments we’ve introduced are having some positive effect. Granted, the number of calls will vary by community – and we encourage agencies and departments to look at their own data to see how 911 calls are affected.
  • Disease acuity. Tied to 911 calls, we are also seeing (based on our data) that the acuity of COVID-19 infections is no less or no more than it was in the early stages of the pandemic. In other words, people are still just as sick – but the impact is different. We will be monitoring the acuity of EMS patients transported for COVID-19 as well as their hospital mortality in the coming months to help gauge the severity of disease in phase 3.

Where do we go from here?

The data show that cases are on the rise and will likely continue to rise. However, the data also show that 911 calls are rising less rapidly than would be expected to rise in comparison to COVID-19 cases.

As we respond during this next phase through the winter, below are some areas to monitor and track at your own agency and department. To see these data and trendlines at a national level to compare to your community, visit the ESO COVID-19 Resource Center.

  • Track influenza-like illness (ILI)
  • Compare cases vs. need for EMS transport
  • Compare cases vs. hospital confirmed diagnosis
  • Compare cases vs. EMS transported mortality
  • Monitor risk-adjusted hospital mortality rates for EMS-transported patients
  • Monitor PPE usage

Stay safe and healthy!

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