- Gregory Katz and Harry Saag are physicians in New York who have been treating COVID-19 patients.
- Working on the front lines of the pandemic, both Katz and Saag say they have witnessed firsthand the risk of the virus and the impact of its spread.
- They say there’s simply not a blanket recommendation for everyone when it comes to deciding whether it’s safe to resume normal activities once restrictions begin to lift; rather, it’s about understanding your personalised risk.
- When advising patients, they err on the side of caution: “The safest strategy is and will remain to stay at home and remain socially distanced as much as possible.”
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Each day, we learn a bit more about the federal plan for reopening the economy, which involves considerable delegation to the governors to set policy for their own states. The federal government is issuing guidelines that highlight a handful of issues that we think are vital to consider:
- widespread testing availability
- contact tracing
- local hospital capacity
We aren’t policymakers; we’re doctors.
So while we have plenty of ideas about the public-health side of things, we aren’t making those decisions.
But we do counsel our patients daily about how to think about these risks.
We agree that governmental restrictions play a role in what people do, but if people don’t feel safe going out in public, economic activity is going to be just a fraction of what it was before the pandemic.
So, is it safe to return to my normal activities if government restrictions are lifted?
Counseling patients on their individual risk is something we do every day for our patients. The difference with COVID-19 is the sheer lack of understanding the medical community has at this time. When it comes to most of the diseases we treat, we use data underlying different possible outcomes in order to make appropriate therapeutic decisions.
For example, when helping a patient decide if they should be taking a daily aspirin to prevent a heart attack, there are validated risk models that help advise a patient of the risks and benefits of choosing to take this medication.
The difficult thing with COVID-19 is that we’re still working on obtaining the right type of information to help each person make his or her own decision. This makes it much more challenging to offer concrete recommendations to individuals with the same clinical confidence we can offer for other conditions.
What do the numbers look like in COVID-19?
We know the approximate risk of death once someone is sick enough to seek medical attention, a number that is called the case fatality rate, or CFR, ranges from about 0.3-3.5% (this being an average risk across age ranges, with higher risk in older folks and lower risk in younger ones).
The problem is that we don’t really know how often people who get infected end up with symptoms of disease to warrant seeking medical care, because we don’t have widespread testing across the asymptomatic population.
In some diseases, almost everyone who is infected gets sick. That doesn’t seem to be the case in COVID-19. So even if we know quite a bit about the CFR, we know very little about the infected fatality rate, which is called the IFR (the number of people who die among all of those who are infected, not just among those sick enough to get tested).
Figuring out the IFR requires widespread antibody testing across the population so that we can determine the overall numbers that have been infected, not just the ones who have been sick enough to seek out medical care.
For example, let’s take a 70-year-old man with no medical problems.
If the IFR is essentially identical to the CFR, our hypothetical patient is looking at an approximately 8% chance of death if he gets infected.
But if the IFR is 1/10 the CFR – meaning that only one in 10 patients infected becomes a “case,” that risk of death for our patient drops to about 0.8%.
That same 70-year-old man coming into the hospital with a minor heart attack also has a risk of death of about 8%.
Across society, the amount of morbidity and mortality, even at a low range of estimates, means an almost indescribable amount of pain and suffering. But for each person trying to decide whether to go back to work, to go to the grocery store, or even to see family, this degree of variation could mean the difference between staying at home in isolation versus going about a quasi-normal life.
How do you know what to do?
The point of an exercise like this is that there isn’t a blanket recommendation for everyone. It is about understanding your personalised risk. A risk that’s reasonable for me might not be one that’s reasonable for you.
One person can look at a CFR of 8% and think, “There’s no way that I’ll go back to my regular life if there’s a one in 12 chance I die if I become sick enough to need medical attention.” But you might look at it and say, “I need to get back to the office and I need to see my family, so I’ll take my chances with a 92% likelihood of survival. Plus, there’s a chance that the numbers are wrong and my likelihood of dying is much lower than that.”
The more clarity we have with our numbers, the more accurate we can feel about these estimates. As it stands now, there’s still a lot of uncertainty, and all of the numbers above must be viewed with several grains of salt.
When we counsel our patients, we err on the side of caution, so that we don’t give people a false sense of security until we have more data.
The safest strategy is and will remain to stay at home and remain socially distanced as much as possible – but it’s up to each of us to assess our own personal risk and make decisions knowing that those decisions come with some degree of risk.
Our hope is that as testing becomes more available and more information comes out of clinical trials, the more comfortable we’ll feel that we’re making those assessments based on reality instead of hope.
Gregory Katz is a cardiologist at the Hudson Valley Heart Centre of Nuvance Health working as an intensivist at Vassar Brothers Hospital during the COVID-19 pandemic. He writes an email newsletter on medicine and COVID-19 that can be found here.
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