3/21/2020 'Flattening the curve’ may be the world’s best bet to slow the coronavirus

Why ‘flattening the curve’ may be the world’s best bet to slow the
coronavirus

By Helen Branswell2 @HelenBranswell3

March 11, 2020

A person checks in at security at an international departure terminal at John F. Kennedy Airport in New York on
March 7. Spencer Platt/Getty Images

For many countries staring down fast-rising coronavirus4 case counts, the race
is on to “flatten the curve.”

The United States and other countries, experts say, are likely to be hit by
tsunamis of Covid-19 cases in the coming weeks without aggressive public
health responses. But by taking certain steps — canceling large public

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gatherings, for instance, and encouraging some people to restrict their contact
with others — governments have a shot at stamping out new chains of
transmission, while also trying to mitigate the damage of the spread that isn’t
under control.

The epidemic curve, a statistical chart used to visualize when and at what
speed new cases are reported, could be flattened, rather than being allowed to
rise exponentially.

“If you look at the curves of outbreaks, they go big peaks, and then come
down. What we need to do is flatten that down,” Anthony Fauci, director of
the National Institute of Allergy and Infectious Diseases, told reporters
Tuesday. “That would have less people infected. That would ultimately have
less deaths. You do that by trying to interfere with the natural flow of the
outbreak.”

The notion that the curve of this outbreak could be flattened began to gain
credence after China took the extraordinary step of locking down tens of
millions of people days in advance of the Lunar New Year, to prevent the virus
from spreading around the country from Wuhan, the city where the outbreak
appears to have started. Many experts at the time said it would have been
impossible to slow a rapidly transmitting respiratory infection by effectively
shutting down enormous cities — and possibly counterproductive.

But the quarantines, unprecedented in modern times, appear to have prevented

explosive outbreaks from occurring in cities outside of Hubei province, where
Wuhan is located.

Since then, spread of the virus in China has slowed to a trickle; the country
reported only 19 cases on Monday. And South Korea, which has had the third
largest outbreak outside of China, also appears to be beating back transmission
through aggressive actions. But other places, notably Italy and Iran, are
struggling.

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For weeks, a debate has raged about whether the virus could be “contained” —
an approach the WHO has been exhorting countries to focus on — or whether
it made more sense to simply try to lessen the virus’ blow, an approach known
as “mitigation.”

That argument has been counterproductive, Mike Ryan, the head of the
WHO’s health emergencies program, said Monday.

“I think we’ve had this unfortunate emergence of camps around the

containment camp, the mitigation camp — different groups presenting and
championing their view of the world. And frankly speaking, it’s not helpful,”
Ryan told reporters.

Caitlin Rivers, an assistant professor of epidemiology at the Johns Hopkins

Center for Health Security, said any lessening of spread will help health
systems remain functional.

We want to hear from you: 5Are you a health care worker affected by the coronavirus
outbreak? Please tell us about your experience.5

“Even if we are not headed to zero transmission, any cases that we can prevent
and any transmission that we can avoid are going to have enormous impact,”
she said. “Not only on the individuals who end up not getting sick but all of
the people that they would have ended up infecting. … And so the more that
we can minimize it, the better.”

On any normal day, health systems in the United States typically run close to
capacity6. If a hospital is overwhelmed by Covid-19 cases, patients will have a
lower chance of surviving than they would if they became ill when the
hospital’s patient load was more manageable. People in car crashes, people
with cancer, pregnant women who have complications during delivery — all
those people risk getting a lesser caliber of care when a hospital is trying to
cope with the chaos of an outbreak.
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“I think the whole notion of flattening the curve is to slow things down so that
this doesn’t hit us like a brick wall,” said Michael Mina, associate medical
director of clinical microbiology at Boston’s Brigham and Women’s Hospital.
“It’s really all borne out of the risk of our health care infrastructure pulling
apart at the seams if the virus spreads too quickly and too many people start
showing up at the emergency room at any given time.”

Related: 6

What does the coronavirus mean for the U.S. health care system?
Some simple math offers alarming answers 6

Countries and regions that have been badly hit by the virus report hospitals
that are utterly swamped by the influx of sick people struggling to breathe.

Alessandro Vespignani, director of the Network Science Institute at

Northeastern University, is gravely worried about what he’s hearing from
contacts in Italy, where people initially played down the outbreak as “a kind of
flu,” he said. Hospitals in the north of the country, which the virus first took
root, are filled beyond capacity, he said, and may soon face the nightmarish
dilemma of having to decide who to try to save.

“This was what was really keeping me up at night, to unfortunately see Italy
approaching that point,” Vespignani said, adding that now that the country has
effectively followed China’s example and put its population on lockdown,
“hopefully this will work.”

Vespignani, along with colleagues, published a recent modeling study7 in

Science that showed travel restrictions — which the United States has adopted
to a degree — only slow spread when combined with public health
interventions and individual behavioral change. He’s not convinced that people
in the United States comprehend what’s coming.

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“I think people are not yet fully understanding the scale of this outbreak and
how dangerous it is to downplay,” he said.

Mina agreed: “Without a very clear signal coming from our government at the
national level, it’s really just like a small trickle as people start to recognize
that this is happening.”

Rivers and colleagues from Harvard’s T.H. Chan School of Public Health have
looked at what U.S. hospitals might endure if Wuhan-scale spread occurred in
this country. Their analysis10, posted on a preprint server in advance of peer
review, came to a chilling conclusion.

“If a Wuhan-like outbreak were to take place in a U.S. city, even with strong
social distancing and contact tracing protocols as strict as the Wuhan
lockdown, hospitalization and ICU needs from COVID-19 patients alone may
exceed current capacity,” they wrote. “We don’t want to go that route,” Rivers
told STAT. “So it’s the top priority right now that we bend the curve.”

As of Tuesday, the Centers for Disease Control and Prevention said there had
been 647 cases and 25 deaths in the country. A website maintained by Johns
Hopkins University — which is considered the go-to website for Covid-19
statistics — scrapes data from a variety of sources. It suggested late Tuesday
afternoon that there had been 808 cases in the U.S. and 28 deaths. Most in the
deaths have been in the Seattle area11.

But the reality is that with state and local laboratories in the country still
getting up to speed with how to test for this infection, the full extent of spread
is not known.

Related: 11

U.S. communities are braced for coronavirus outbreaks. Seattle is

already in the thick of it 11

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Without that kind of data, public officials have been loath to take the types of
measures that would help to flatten the country’s epidemic curve. Those
measures include banning concerts, sporting events, and other mass
gatherings, closing movie theaters, telling people who can telecommute to
work from home, and potentially closing schools. (The jury is still out on how
much school closures would help slow spread.)

“I think that in terms of the decision-makers, we are in a place right now

where we don’t have the data we wish we had in order to inform these
decisions,” Rivers said. “So what I think we’re seeing is decision-makers
struggling to pull the trigger on these really big, impactful decisions without
having a clear sense of the current status.”

“But we know from pandemic planning and previous experiences that the
sooner we implement these measures, the more effective that they are,” she
said.

Mina said the lack of evidence of widespread transmission in the country may
be making people feel any aggressive step right now may be an overreaction.
But this is precisely the time when public health measures of this sort can have
an impact, he said.

“We are all wondering if our actions are melodramatic. And we’re feeling
silly,” he said, noting people still feel self-conscious bumping elbows instead
of shaking hands.

“But this is the problem, that people aren’t recognizing that we are at this
moment and we can make a decision right now to flatten this curve by …
being OK with wondering if we’re being melodramatic,” he said.

“Should we be canceling classes? Should we be canceling our flights? Should

we not be shaking hands? All of these things are things that I want the public
to keep wondering if we should be doing this. Because the moment we’re no
longer wondering whether we should be doing it, it’s too late,” Mina said.
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“That means that we know we should be doing it. And that is a bad place to
be.”

Andrew Joseph contributed reporting.

About the Author

Helen Branswell2

Senior Writer, Infectious Disease

Helen covers issues broadly related to infectious diseases, including outbreaks,

preparedness, research, and vaccine development.

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@HelenBranswell 3

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