What Keeps Me Up At Night

It is a common question that I have gotten, ever since I became a CEO more than 14 years ago – “What keeps you up at night?” I also get it now in regards to the coronavirus pandemic. I never tell anyone all the things that I am losing sleep over. It doesn’t do anything but cause others to lose sleep. The only fears that I share are ones that I think will actually benefit others to be aware of.

I was asked this question a couple of months ago in response to whether I was concerned about hospital bed capacity in Idaho. I replied that it wasn’t in my top 25 of things I worry about. A local business leader tried to Twitter-provoke me implying I should be worried about it. There are so many things to worry about, I have to prioritize my time spent worrying. He didn’t know what was in the top 25 on my worry list, or he would have understood why worrying about hospital capacity didn’t make it.

But time has passed. We have learned so much in the past two months. My list has evolved, but it hasn’t changed that much. I am not going to share my top 25 list, but I am going to share with you a few things that are on it, especially since some of these concerns have now made it into the press.

If you have followed my blog or discussed this issue with me, you know that I have been concerned for sometime about the predictive models that have been circulating in the media and online. They generally show a very nice, symmetrical bell curve graph that generally ends sometime this month or later this summer. Oh, that this were true. It would be wonderful. However, all of these models are inconceivable to me.

Why? Because the best guesses are that no more than 5 percent of the U.S. population has been infected with SARS-CoV-2. The limited antibody testing data available seems to support this. In fact, for Idahoans, that infection percentage is likely less than 2 percent.

As I have written previously, the lowest estimates are that it will take 60 – 70 percent of the population to be infected and/or immunized in order to slow down the transmission of the virus to the extent that the vulnerable and susceptible among us are relatively protected.

The only reasons that SARS-CoV-2 would stop causing infections this summer include (1) the attainment of herd immunity through natural infection (however, as I stated, best estimates are that only 5 percent of the country has been infected, so it is not reasonable to think we could get to the levels required for herd immunity anytime soon), (2) the attainment of herd immunity through immunization (however, there is no basis to believe that we could have an effective vaccine much before the end of the year, and even that would be an extremely aggressive timeline. Many experts are skeptical as to whether we will even have a vaccine next year), and (3) the virus mutates in such a way as to be far less contagious.

The SARS-CoV-2 virus is an RNA virus. RNA viruses are well known to mutate frequently. We know that there have already been at least 14 mutations of the SARS-CoV-2 virus just since late December/early January. Unfortunately, a mutation that probably occurred in February has already resulted in the virus likely being more contagious, not less and is likely the predominant, but not only, form circulating in Europe and the U.S.

My concern is that people seeing these depictions of models showing an end of disease activity this summer, the talk of reopening the country and getting back to work and school, and the early messaging about winding down the White House Coronavirus Task Force may lead many people to believe that we are nearing the end of this pandemic.

So, if the bell curve depictions are wrong or misleading, what does the future look like? With the caveat that no one knows for sure, I think a better depiction would look like a series of waves, where activity waxes and wanes. In other words, the number of infections will increase significantly, and then we will reinstate countermeasures that will bring the cases back down. But, with this said, I don’t expect that all the waves look the same. And, these waves will not look the same all across the country. The waves will be of greater amplitude in those cities of our country with mass transit, international airports, high population density and less effective social distancing.

So, if the virus is not going away this month or in the next couple of months as many of these diagrams suggest, what do these waves look like for the rest of 2020 and when do they come? There has been hope that the transmission of the virus would decrease over the summer with increasing temperatures, increased humidity and people being outdoors more. While we can still hope that is the case, it doesn’t appear very likely. First, we did not observe this in the southern hemisphere as those countries went through their summers. Additionally, it is likely that even if transmission is somewhat decreased, it may be offset by the large part of the population that remains susceptible to this virus (perhaps 95%). Further, my expectation is that we will see new waves of disease in the next three to four weeks (end of May/early June) that will result from reopening of communities in some parts of the country that are opening too much, too fast. Additionally, as travel resumes, we will have people bringing the virus with them to communities where they can significantly increase spread.

So, expect another wave by early June. I don’t think it will be as big as the first wave we have just been through since high risk individuals are largely continuing to stay isolated and even with the reopening, many people are choosing to continue to be reluctant to return to work, shopping and other activities until they see how things evolve.

On the other hand, I am worried about people who are falsely reassured by positive antibody tests. These tests are becoming widely available despite widely varying accuracy, a significant risk for false positive tests in low prevalence areas and a lack of evidence as to whether antibodies confer immunity. False positive tests could cause persons to exercise less prevention measures thinking that they are immune. We do know that most (but certainly not all) people who become infected do make antibodies to SARS-CoV-2. However, the immune response to SARS-CoV-2 is very complex and antibodies are only one small part of the body’s response. Antibodies are not produced until a week or more after infection. The initial immune response is non-specific (the innate immune response). If the virus survives this initial defense, it enters into cells to replicate and antibodies cannot reach the virus when it is inside cells. But, as virus is replicated in the host’s cells, the virus is released and antibodies can attack the virus. But not all antibodies do so or are effective in neutralizing the virus. We don’t know whether the antibodies to SARS-CoV-2 virus neutralize it, though there is good reason to expect that this might very well be the case. There are other viruses that also stimulate antibody production, but the antibodies do not provide immunity and do not stop the infection from continuing on, so we must take care to ensure that antibodies to SARS-CoV-2 are truly protective before we provide individuals with positive tests that impression or that reassurance.

We do expect that antibodies will confer some degree of immunity, but we do not know for how long. It could be for weeks, months or even a few years, but we don’t know. Further, the mutations identified that I referenced above have raised the question as to whether someone who is previously infected and develops immunity is immune from reinfection with the virus form that has mutated. Without answers to these questions, we run the risk that people who believe they are immune take fewer precautions and actually become risks for contracting and transmitting the virus. Plus, we don’t know whether the tests we have available that were designed to detect the original virus nucleic acids, antigens or antibodies will detect the new forms of the virus after multiple mutations.

So, after a next wave in late May/early June, I fear a bigger wave in the fall. Although there are important differences between this coronavirus and the flu, past influenza pandemics do give us some important insights into what might happen with this coronavirus pandemic given that coronavirus and influenza are both respiratory viruses and transmitted in similar ways, though there are reasons why the coronavirus is more of a threat due to greater contagiousness, a longer incubation period, a longer period of asymptomatic or pre-symptomatic viral shedding, etc. In several of the past influenza pandemics, a small wave of infection occurred in the early part of the year, as we have just been through, followed by a significantly larger wave about six months later in the fall. This happened with the 1918 – 1919 Spanish flu pandemic and the second wave was much deadlier. There is speculation that the influenza virus may have mutated during the time between the first and second waves. The longer the virus continues to spread, the greater the chance for mutations that will make the virus more contagious and/or more deadly.

I fear we could see this happen. And, unfortunately, late fall is also when we see the resurgence of other respiratory viruses, so it may be harder to detect COVID cases, as it was at the beginning of this year. I fear that this means cities like New York, New Orleans, and Seattle could be in for an even larger outbreak of this virus than they have just been getting behind them, and I am sure that this is unimaginable for them.

Of course, it is also possible that Americans will sustain their efforts at social distancing and good hand hygiene for the next year or years until we do have a vaccine or achieve herd immunity through natural infection. This could mean that we have ongoing waves, but of low amplitude that do not overwhelm our health care system and do not disrupt our lives as much as happened over the past couple of months. On the other hand, I fear that the SARS-CoV-2 virus might mutate enough to evade our immune systems so that it becomes a recurring seasonal infection much like influenza, and even if we have a vaccine, we may need to get periodic vaccines to adjust to new strains of the virus.

Obviously, effective therapeutic options that taken early might prevent serious illness and deaths and/or an effective vaccine would be game changers and allow me to remove many of these concerns from my top 25 list.

Until then, I encourage Americans not to let our guard down and our federal and state governments and local hospitals and health systems to use this time of relative recovery over the summer to prepare for a potential second wave in the coming weeks and a potentially severe third wave this fall.