On March 10, 2020, I addressed the question, "Could Covid kill 1 million Americans?"

I recalled my first meeting with President Obama @BarackObama. It was in the Roosevelt Room of the White House, just as the H1N1 pandemic was beginning to spread widely. The President asked: “We’re not going to see a million deaths in this country, are we, doctor?”
I replied, with more certainty than I felt, “No, Mr. President, we won’t.” Fortunately, that was correct.

In early March 2020, if asked the same question about the Covid pandemic, I would have had to answer: “I hope not, but that’s a possibility.”

Here's how epidemiologists think about that question. How infectious is the virus (now-famous, formerly obscure Ro) and how deadly (infection fatality ratio - the proportion of people who get it who die)? We summarized that in a table in this article. bit.ly/35s0nwm 4/
Worth looking closely at the table. We didn't know infection fatality ratio, but estimated it could be as low as 1 in 1,000 and no higher than 1 in 100. (We wrote of case fatality, but infection fatality is more useful to calculate). We now know that it's about .5 (1 in 200). 5/
That's "moderately severe" tho we now know it's very different in different ages. For kids, it's like a seasonal flu. For the elderly, it's equivalent to a very severe flu – like 1918 pandemic (graph). Now look at the columns. What proportion of the country will get infected? 6/
Here's where the answer to the question may need to change – because of new strains such as B.1.1.7. Our March 2020 table stopped at 50% infection. With moderate severity that would be >800,000 deaths in the US (fewer if we improve treatment and reduce the fatality ratio). 7/
But what's to say Covid will stop at 50%? We're already at around 25% in US and every day about a million more get people infected. (Diagnosed cases increasingly far below infections.) That's 7 million or 2%/week, 8%/month. And that's BEFORE the variant spreads widely here. 8/
So today I'd have to answer, "Could Covid kill a million Americans?"

"Quite possibly. Especially if B.1.1.7 or another more transmissible strain spreads widely."

That's more Americans than killed in all wars of 20th Century and close to number killed in war since 1776.

Here's how we concluded that essay exactly 10 months ago to the day:

"It’s been said that a week is a long time in politics. With COVID-19, a week is not a long time, it’s an eternity. The sooner we act, the more we can decrease the likelihood of a million deaths in the US." 10/
We added:

"Clear, consistent communication from credible sources builds public trust and saves lives. When faced with a scenario in which so many Americans could die, there’s no time for politics."

Oh well. Didn't happen. But here are 5 things we can do right now.

1. Scale up vaccination, especially nursing home residents and staff and people over age 65. This will greatly reduce deaths, even without changing the epidemic trajectory. Vaccines won't change the shape of overall pandemic curve for months. 12/
2. Scale up effective treatment. Monoclonal antibodies given early in illness likely prevent hospitalization. We need to scale up their use in outpatient settings. Doing so also won't bend curve of the pandemic, but will spare hospitals and likely save lives. 13/
3. Limit time indoors other than with household members. Outdoors is generally ok. The more time you spend indoors with people from outside your household, the more the virus spreads. Limit travel, because when we travel, the virus travels and viral spread accelerates. 14/
4. Mask up. Almost any mask greatly reduces spread from someone with the virus. But to protect ourselves better, we may need N95/KN95 when indoors near others. A more infectious strain requires stronger defenses. Masks all the time when around others not from your household. 15/
5. Test, trace, isolate, quarantine. Antigen tests have limits but widespread testing can reduce number of superspreading events. Anyone feeling ill must isolate. Exposed susceptible people must quarantine. Society must support both groups to do so. Find and stop outbreaks. 16/
We are absolutely getting numb to the numbers. 23,000 dead in the past 8 days. 100,000 per month. 500,000 by March 1 or before.

So much of this was preventable. But we are where we are. 17/
Let's double down on protection protocols. Federal, state, city, local governments, health departments, health care providers, civic organizations–everyone– must work together on these 5 measures: vaccinate, treat, limit indoor time, mask, test/follow-up to stop outbreaks. 18/
A pandemic isn't like the weather – able to be described and sometimes predicted but not controlled. All of our actions matter. A lot.

So the right answer, if asked today, to the question, "Could Covid kill a million Americans?" is:

"Only if we let it."


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More from @DrTomFrieden

9 Jan
Covid Epi Weekly: Humanity vs Virus – the Virus is Winning

Perfect storm: 1. Uncontrolled spread in most of US, 2. Slow vaccine rollout, 3. Worrisome mutations increase transmissibility and could undermine diagnostic testing, antibody treatment and vaccine efficacy.

A misleading narrative suggests that uncontrolled spread of Covid shows that public health measures don’t work. The plain truth: most places didn’t stick with the program long enough to get cases to a manageable level and now masking and distancing aren’t being done reliably. 2/
So yes, if you don’t use masks correctly and consistently, they don’t work. And vaccines don't work if people don’t take them. CDC data getting ever more available and useful; Covid Tracking Project remains invaluable. bit.ly/3q2jAMm 3/
Read 30 tweets
4 Jan
Which places have done the best job of protecting people from Covid? A thread.
Best at early action: TAIWAN. Quickly halted flights, quarantined travelers, implemented widespread testing, and quadrupled face mask production within a month. The US now has more cases and deaths every 5 minutes than Taiwan has had to date.
Best at learning from recent epidemics: LIBERIA. Hit hard by Ebola in 2014, Liberia was one of the first countries to screen for Covid at airports and implement comprehensive control measures, including rapid testing, complete contact tracing, and effective quarantine.
Read 10 tweets
19 Dec 20
Covid Epi Weekly: First Sighting of Vaccine-Induced Immunity

Imagine: You’ve been on a dangerous sea voyage. One of 200 people >65 have died. Safe land is sighted in the distance. Everyone on board must do everything possible to reduce deaths until safe harbor is reached. 1/17
A tale of two realities. Worst spread in US since pandemic started. Highest case, hospitalization, and death rates. Continuing high levels of spread. And at the same time, the most hope we’ve had for a beginning of the end, with highly effective, safe vaccines rolling out. 2/17
First, the epi. GREAT that CDC and HHS have finally been allowed to release — TODAY!!! — some of the information they have. This belongs to the public, not, dammit, to anyone in Washington. The headline says it all ... but 10 months too late. beta.healthdata.gov/download/gqxm-… 3/17
Read 18 tweets
12 Dec 20
Covid Epi Weekly: A Week of Great Progress for Vaccines…But Also, Unfortunately, for the Virus

Encouraging vaccine news but deeply discouraging lack of action to stop pandemic. Coming weeks will be devastating but numbness to suffering is spreading as rapidly as the virus.1/10
First the good news. Good transparency about vaccines; data about as good as could be. Highly effective including for older people (tho few frail elderly included), and against severe infection. No serious adverse events - but need to track for this when millions vaccinated. 2/10
The road to immunity through vaccination will be bumpy. Production, supply, distribution, uptake, possible adverse events - all huge challenges. New vaccines will likely be approved in the New Year. An enormous challenge, but if the communication is done well, can succeed. 3/10
Read 10 tweets
10 Dec 20
Tens of thousands of people have already been vaccinated as part of Covid clinical trials. We haven't seen any significant safety concerns so far, and the FDA just gave an emergency approval for the Pfizer vaccine. Let's talk more about vaccine safety. 1/
An independent committee conducts their own analysis of clinical trial data for all vaccine candidates. Covid vaccines are no exception, and this week the committee released its analysis of the Pfizer vaccine. Vaccine efficacy in preventing Covid after two doses was 95%. 2/
After the second shot, most people in the clinical trial had headache and fatigue and 10-15% felt feverish; this went away within a day or so, and is a sign the vaccine is working. No serious adverse reactions have been identified. 3/
Read 8 tweets
5 Dec 20
Covid Epi Weekly: Public Health Waking Up From Politics-Induced Coma

Cases, hospitalizations, deaths worsening. Vaccination coming - let’s make sure as many of us as possible live to see that day. We must double down on protection protocols. Together, we’re stronger and safer.1/
Highest case, hospitalization rates in US ever. Cases cresting in much of midwest, still very high. Some of decrease in past week: less testing/care over holiday. My father, who ran intensive care units, commented: “Only very sick people come in on Thanksgiving and Christmas.” 2/
Cresting doesn't mean low. “Lower”: “sky high but not quite as sky high”. Stunning: more than 1 in 3 people in S Dakota infected. By Jan 20, if it were a country, it would have highest death rate in world: ~1 of every 60 people over age 70 killed by this preventable infection. 3/
Read 17 tweets

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