Four Ps: Pandemic, Panic, Plan, Prepare

Many of us involved in pandemic planning do so to avoid panic. We focus on the need to prepare. The crush on public health infrastructure has meant the planning didn’t lead to preparation, and that has led to panic as the pandemic set in.

We must avoid repeating, or continuing, this mistake. I’m not just talking about planning for the next pandemic. I’m talking about planning and preparing for THIS one. It’s easy to say “we just need to put out the fire.” But if we only focus on the fire in front of us, we ignore those fires that are igniting all around us.

We need to anticipate the hotspots before they become full fires. This IS the essence of public health — prevention.

We do this by Testing, Tracing, and Tracking.

Testing: It requires quick results. That isn’t happening, even though we’ve ramped up capacity. We must not pull back now.

Tracing & Tracking: Case investigation and contact tracing are valuable tools in an outbreak. This is true even when we’re lagging so far behind. We won’t get all the cases, we won’t find all the contacts. We need to try. We need to find the secondary and tertiary contacts before the next ring of contacts are exposed. It may seem like we’re drowning, but we can’t stop. In malaria research, I often said it was like spitting in the wind. But we still do it, we find new ways, better ways, and we keep at it.

We don’t wait for the new fire to start.

So where are we now?

A Little Bit Orange in San Antonio.

As of Saturday, July 25, we’re sitting right at the border between RED and ORANGE. Critical and Severe. A few days ago we were well into the critical. Reporters have asked about cases and hospitalizations plateauing (see graphs below). Yes, we are seeing some leveling off, but when that happens at the critical, high point, we’re this >< close away from the tipping point. We need to substantially decline before we can feel better about a plateau. But hey, we’ll take our small wins.

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In Bexar County, our case numbers are increasing, our deaths are increasing. This graph doesn’t look a whole lot different from last week. The blue bars are the number of positive lab reports per day. Again, those may reflect cases who were symptomatic more than a week prior. The red line is the moving average. There is no doubt it continues to climb.

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% Positive Tests

One of the indicators we follow is the percent positive tests. If we have a very high rate of positivity, it usually means we’re not testing enough — we’re only finding those who are very ill and are obvious cases. That’s what we were doing in April. This is important for diagnostics, but we also need to find those who may be infected but not so ill they require hospitalization. These are the folks likely to transmit the virus to others. As we continue to expand testing, we’ll find more cases but we’d expect the % positive to decline. For the past month, we’ve been averaging 2500–3500 tests per day. Throughout June and July, the positivity rate did the opposite: it jumped. It appears to have dropped in the past week, but we won’t know if this is “real” until another one to two weeks.

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Even more concerning is the continued increase in cases in young people. Of the more than 30,000 cases, 14% are in people under the age of 19. Since July 1, this age groups makes up 17% of new cases. Similarly, as of May 1 (so exposed late April), only 17% of cases were in people in their 20s. Now they make up 23%.

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Back to the Hospitals

The biggest concern continues to be hospitalizations. This graph may be a little misleading. The blue bars represent the percent of active cases who are hospitalized. There’s a huge jump because the number of active cases dropped suddenly. This is likely due to data input catching up. Unfortunately, it shows that of the 5,780 active cases, about 20% have been hospitalized recently. The actual number of hospitalized cases has begun to decline in the last few days, but remember, daily reports don’t mean a whole lot. We need to see decline over 14 days. And in the case of hospitalizations, we need to see a substantial drop to feel like we have sufficient wiggle room to take on new cases. At the moment, only 11% of staffed beds are available.

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Not surprisingly, as more young people are infected, more young people are being hospitalized. That overall percentage for 0–17 year olds may seem small, but it’s grown by 2% in the past six weeks. And it’s not just older teens. Nearly the same number of children ages 0–9 and 10–19 have been hospitalized. For those older than 40, the rate of hospitalization has been consistent or dropping. While almost 30% of ALL those hospitalized have NO co-morbidity, 68% of those under 19 years old have NO co-morbidity.

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We still have a lot to learn about COVID-19 in children. We know that children can and do get infected, and some get very sick and some even die. It’s unclear how significant their role is in transmission. So far, it looks like they’re more likely to become infected from an adult member of their household than from another child. But since March, most children have only interacted with members of their household. We’ve seen some cases in summer camps, suggesting transmission is possible. And while there have been many cases in daycares, none of these appear to be linked to outbreaks.

Tests, Round II

A note about tests and how data are reported. Recently, the state decided to change its recording of lab tests. Now, only RT-PCR tests, the ones that detect the viral genome, are considered “confirmed.” These tests are taking 10–15 days to be returned. That means 10–15 days before case investigations can happen.

Antigen tests, which identify the present of a viral protein (and are highly specific — i.e., if it’s positive, it’s positive) are now reported as “probable.” These are rapid tests, you can get the result in 30 minutes. They have a false negative rate that is higher than we’d like (10–17%). A false negative means that you can have a negative result but really be positive. That’s risky. We trade off sensitivity for time.

But a positive is a positive.

In practice, both of these should be considered true cases. And both need to be deployed. And we need to improve lab capacity for RT-PCR tests.

Antibody tests look for the presence of antibodies which indicate you were infected in the past. In theory, that means you’re immune. But these tests have been unreliable and mean nothing diagnostically. Texas Department of State Health Services has useful document explaining each: COVID-19 Testing Explained.

The Four Ps

We’re well into this Pandemic. We have Panicked. We have Planned. Now we need to Prepare. Even if we come out of this first wave, a second will be coming. That means case investigators, contact tracers, improved LAB capabilities, hospital staffing (including retraining if necessary).

We can’t slow down, even if our cases numbers start to decline. We need to prepare for the next wave. We’re still at the top of the first.

As usual, all Bexar County data comes from the COSA website:

Dr. Rohr-Allegrini is an epidemiologist and tropical disease scientist currently working to prevent diseases through immunizations.

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