Today, any one of us could be spreading the coronavirus unknowingly. That is the implication of two key phrases that should be top of mind for everyone: “community spread” and “asymptomatic transmission.” A third phrase that may within days or weeks be on the front page is “overwhelmed health care system” — do not assume you will have a mild case and do not assume you will get the care you need if you become critically ill. All levels of government should be offering the strongest possible leadership on “social distancing.” Governor Baker’s recent announcements appear further below.
Community spread
On Friday, March 13, the Massachusetts Department of Public Health issued guidance to health care providers acknowledging that “Massachusetts has now begun to see some initial evidence of community spread of COVID-19.” That means that the virus has broken out of known person-to-person chains of infection. It is no longer, “I had dinner with a friend from China who was coughing.” People are being diagnosed with the disease but no one knows where they got it. The virus is loose in the community and anyone could have it. Right now, the chance that you personally already have the virus is still very low, but the virus is likely spreading exponentially so the odds are getting worse by the day.
It is easy to get the disease from another person. The CDC says, “The virus that causes COVID-19 seems to be spreading easily and sustainably in the community (“community spread”) in some affected geographic areas.”
The stories about the Biogen meeting paint a grim picture of just how easy it is to spread the virus and how far out of control the virus likely already is. First contemplate that, as the Globe reported on March 11, roughly 50 out of 175 conference attendees had been identified as sick within days of the conference. Apparently these cases derived from perhaps just two conference attendees from Europe. Business meetings can involve a lot of warm greetings and shared meals, but there has been no suggestion that this meeting involved any truly unusual behavior that might elevate the rate of transmission. As of March 14, two weeks after the meeting ended, 104 people have tested positive who can trace their exposure to the conference.
Now, appreciating how easy it is to spread the disease in normal social interaction, contemplate that the conference ran from February 26 to February 27 and that it was not until March 7, more than a week after the conference, that 60 Marriot Employees were brought over to Brigham for testing. Then on March 12, two weeks after the conference ended, public health authorities closed the Marriot “in the interest of public health.” Consider all the hotel servers, doormen, desk clerks, and room cleaners who were likely exposed to the virus, not to mention other guests and workers in nearby restaurants. The Reddit thread about the Marriot employees includes a lot of telling comments, for example: “I guess it’s just scary how relevant it is to my life now, since I’m clearing dirty dishes and napkins all day. Also people are just super gross in general.” There was little explanation offered for the closure, but it is a fair inference that after another two weeks of working together some employees were sick and basically all the employees of the hotel should be quarantined and the entire hotel sanitized. Consider all of their family members exposed over the days of delayed response. Again, not to mention a new population of guests who cycled through the hotel.
The “serial interval” is the number of days between a person getting infected and a person infecting the next person in the chain of infection. Emerging literature from China (collected here) suggests that the serial interval averages around 5 days for COVID-19. The delayed responses to the emerging cluster gave plenty of time for the virus to spread among employees of both Biogen and the hotel and, of course, their families and friends.
Finally, set this story against the backdrop of a shortage of testing. The Globe reported that many of the Biogen employees who sought testing were initially turned away. More recently the Globe quoted a physician on the South Shore, “I feel, as a physician, like I’m pretty paralyzed by this, I think that’s the only word I can use. Paralyzed. I’ve never been in a position like this in my life . . . It’s been very strange to want to test for something, and have a high clinical suspicion for something, and not be able to do it.” See also the physician’s Faceboook thread. In the absence of a definitive diagnosis through testing, it is less likely that symptomatic people or their employing organizations will take all necessary precautions to avoid infecting others. For example, it took 5 days from the first employee showing symptoms for a general warning to go out to Biogen employees, during which time many Biogen employees mixed with those who attended the conference.
Asymptomatic Transmission
As of March 15, 2020, the official CDC position is that most transmission of the virus occurs when people are symptomatic — coughing and spewing drops of mucus and saliva that are teaming with viruses. The CDC says:
People are thought to be most contagious when they are most symptomatic (the sickest).
CDC, How It Spreads as of March 15, 2020
Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads.
Update: As of April 2, the CDC now acknowledges asymptomatic spread.
Some recent studies have suggested that COVID-19 may be spread by people who are not showing symptoms.
CDC, How It Spreads as of April 2, 2020
The World Health Organization goes a little further. While similarly discounting the risk of asymptomatic spread, WHO acknowledges the possibility of spread through people with mild symptoms:
The main way the disease spreads is through respiratory droplets expelled by someone who is coughing. The risk of catching COVID-19 from someone with no symptoms at all is very low. However, many people with COVID-19 experience only mild symptoms. This is particularly true at the early stages of the disease. It is therefore possible to catch COVID-19 from someone who has, for example, just a mild cough and does not feel ill. WHO is assessing ongoing research on the period of transmission of COVID-19 and will continue to share updated findings.
WHO, News Room Q&A, as of March 15, 2020
Update: As of April 2, the WHO no longer discounts asymptomatic spread.
People can catch COVID-19 from others who have the virus. The disease can spread from person to person through small droplets from the nose or mouth which are spread when a person with COVID-19 coughs or exhales. These droplets land on objects and surfaces around the person. Other people then catch COVID-19 by touching these objects or surfaces, then touching their eyes, nose or mouth. People can also catch COVID-19 if they breathe in droplets from a person with COVID-19 who coughs out or exhales droplets. This is why it is important to stay more than 1 meter (3 feet) away from a person who is sick.
WHO, News Room Q&A, as of April 2, 2020 (emphasis added).
It seems scientifically clear that asymptomatic transmission does, in fact, occur sometimes. A recent letter in the New England Journal of Medicine carefully documents a chain of asymptomatic COVID-19 transmission.
The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak.
Transmission of 2019-nCoV Infection from an Asymptomatic Contact in Germany, NEJM, March 5, 2020
What is not clear is what portion of all transmission is asymptomatic — it could be a lot. A non-specialist’s review of emerging literature from Asia concluded that the serial interval is less than the incubation period for COVID-19. In other words, people are typically transmitting the virus before they have symptoms. The reviewer explicitly did not claim that this finding was “settled science:”
Strong evidence points to presymptomatic sources as a major source of COVID-19 infections, possibly the majority. The exact proportion is environment-dependent; awareness and public health measures reduce symptomatic transmission more than they reduce presymptomatic transmission.
A Significant Portion of COVID-19 Transmission Is Presymptomatic, LessWrong, March 14, 2020
Some experts are convinced that people who feel more or less fine are an important part of spreading the virus:
Asymptomatic and mildly symptomatic transmission are a major factor in transmission for Covid-19. . . . They’re going to be the drivers of spread in the community.
Dr. William Schaffner, identifed by CNN as a professor at Vanderbilt University School of Medicine and longtime adviser to the CDC
National leaders are starting to recognize the possibility of asymptomatic spread:
Until you really understand how many people are asymptomatic and asymptomatically passing the virus on, we think it’s better for the entire American public to know that the risk of serious illness may be low, but they could be potentially spreading the virus to others. That’s why we’re asking every American to take personal responsibility to prevent that spread.
Dr. Deborah Birx, national coronavirus response coordinator quoted by CNN.
Finally, back to the Biogen conference, it appears that none of the participants has admitted being symptomatic at the time of the conference. The likelihood of asymptomatic spread makes our current shortage of testing all the more troubling. If people are not seeking testing until they have symptoms, then with many people still going about their business in our limited shutdown, a lot of transmission is likely going on.
View CNN Video on asymptomatic transmission
Overwhelmed Health Care System
The reassuring mantra is that, “Most people will have mild disease and get better without needing any special care.” That appears be a consistent finding and the true mortality rate is hard to know because many cases may go undiagnosed. On the other hand, many people, including some young people, do need hospitalization. The heartbreaking testimony from Italy shows that if the epidemic is not controlled it can overwhelm the best health care systems in the world, forcing doctors to ration lifesaving care. Italy has more hospital beds per capita than we do — it can happen here.
So, as more and more people understand, the challenge is to “flatten the curve” so that when the epidemic peaks, we still have enough capacity to care for people. The New York Times has a lovely graphic opinion piece about how bad things could get. One of the key takeaways is that it’s way too late to worry about stopping incoming cases. We have thousands of people sick and they are transmitting rapidly enough to double the case load every six days. In the absence of effective vaccines or drug treatments, we just have to move more quickly on social distancing and that is not easy politically.
Early in the epidemic it is very difficult to muster the political will to implement costly, disruptive disease-control policies. . . . What we are hoping to show here is that the calculus is one of short-term pain for long-term gain: Early, aggressive social distancing can substantially reduce the toll of epidemics, which can include the near collapse of health care systems, as we’re currently seeing in Italy.
Epidemiologist David Fisman, Quoted in New York Times, March 13
Many voices are calling for a much more aggressive social distancing program led by government. I join those voices and will be advocating for that in every way I can.
- Social Distancing — this is not a snow day
- Coronavirus: Why You Must Act Now
- State and Local Governments Must Take Much More Aggressive Action Immediately To Slow Spread of the Coronavirus
- Newt Gingrich in Newsweek: I Am in Italy Amid the Coronavirus Crisis. America Must Act Now—And Act Big
- Medium: Act today or people will die
It’s wrong to claim certainty, but the epidemiological analysis suggests that the costs of delay could be unacceptable. Now is the time to pull all the levers we can reach to slow the spread. Close bars, restaurants, and entertainment venues, close the schools, work on messaging to parents and kids about staying home instead of walking the malls . . . get ahead of the epidemic, rather than waiting for it to hit in its full viral fury.
Actions taken by Governor Baker on Sunday, March 15 at 6PM
- Close all the schools in the state for 3 weeks.
- Prohibit on-premise service of food or drink in restaurants or bars (but permitting take out food).
- Prohibit gatherings of over 25 people, excepting legislative bodies and the courts.
- Limit visitors to nursing homes and long-term care facilities.
- Expedite licensing of nurses from other states (previously ordered)
- Anticipated or informal actions
- Directive to all health insurers to cover telehealth services
- Registry of Motor Vehicles guidance extending renewals so people residents do not need to visit the RMV for renewals at present
- Directing hospitals to cancel all elective procedures beginning on Wednesday to create additional capacity in hospitals to treat COVID-19 patients
- Filing emergency legislation on Monday 3-16 to relax Unemployment Insurance guidelines, including waiving the one week waiting period to collect unemployment and expanding eligibility for collecting unemployment for people who have been impacted by COVID-19
- Filing emergency legislation on Monday to help municipal governments with town meetings and adopting budgets
I fully support these actions. They are a big step forward. We likely need to go further very soon, but these were the key next steps that I have been advocating for — I had focused particularly on the school closures. I look forward to hearing from people on additional steps that seem appropriate.
Thank you to many constituents for sharing insights on the pandemic with me. Special thanks to Ben Kuhn who identified many of the resources cited to in this piece. See also the epidemic visualization he developed.
What I’ve been doing since Tuesday (3/10), assuming asymptomatic spread (i.e., I could have it and not know it, so could anyone else) is sanitize my hands before entering a store to protect everyone else, and then again when I leave to protect myself. If they have sanitizer, great, if not I have a small spray bottle of alcohol in my pocket for that. Wipe down your shopping cart handle or basket, too, for yourself and everyone else. Don’t touch your face indoors, if it takes gloves to remind you of this, wear gloves in the store.
And, also, be sure you have a list prepared before you go, map out an efficient path through the store if you can, less dawdling and less touching is less transmission.
Spot on — thanks, Dave
Great advice, thanks
Clear, sound advice. Thank you, Dr. Chase.
I’m not a real doctor. It’s just my initials, and too much education.
Thanks Will for assembling a thoughtful outline of the current situation.
There needs to be more straight-forward, no-nonsense leadership like this, except on the state level. I don’t think it’s possible on the national level, except for some medical experts. Even the CDC has been exposed, causing needless and serious delay in testing. Without panicking, we have to buck up and do better. The consequences of inaction are simply not worth it.
Thank you for giving us the truth. We need to do what’s needed to defeat this virus. We’re not giving up our freedom we’re sacrificing for the common good. In times of crisis that’s what good citizenship requires.
Thank you Will, this is so important. Hopefully Gov. Baker will take more action soon. Maybe add gyms to the list of places to close?
My gym, Gymit, posted that it’s closing from tomorrow (Tuesday) so others might do so as well. Let’s hope.
Will, you’re doing a terrific job. Thank you for your extraordinary diligence. You and your followers might be interested in streaming the link below, a remarkable recent conference of collaborating Broad Institute, MGH, and Harvard Med. School researchers and doctors detailing what they know so far, and what they’re learning as I write. Some of the biology is quite technical, but the overall information is expansive and eye-opening. They believe that the infected asymptomatic population is definitely shedding virus and infecting others. You are impressively on top of all of this! I couldn’t agree with you more on the importance right now of mandatory comprehensive closing of all the institutions you’ve mentioned, including restaurants, gyms, and stores other than food markets. Thank you for all you do!
Stay well,
Susan Heideman (Fred Hapgood’s wife)
Susan, can you please provide the link you mention in your post?
Thank you
Thank you for your informative article. The idea of asymptomatic spread is terrifying and should encourage every person capable of doing so to put him/herself in quarantine! Spread could be exponential!
Well written.
Thank you Will. Shared your first msg widely. Men’s group at my church did not meet Tuesday am, and church is now closed.
HDC did not meet on Thursday. Many thanks.
Thanks, Will. As usual you are a great source of information.
Wondering if there’s a way to prove that #ShutdownMass would be definitively shorter now than later, given 1.5 million U.S. tests/week starting in a week, increasing to 5M/wk. (https://bit.ly/3d7348v), and maybe 2,000 actual infections in Mass. Showing that it would be shorter now than later could help to convince the broad biz community to support an earlier but shorter shutdown.
Excellent information, it is too easy to be seduced by wishful thinking that the situation is so bad.
Your comments are a good thing wake up call… shout it out as much as possible and thanks.
Thank you, Will. We so appreciate your thoughtful leadership. Now, if we only had more of you in office….
Just for clarity regarding the U.S. ability to provide the care you may need. Although Italy has a higher percentage of hospital beds per person then we do, we have more than twice as many ICC /CCU beds per person then they do and it is these type of beds/facilities that we need to treat those who may need critical care. Stay safe and try to mitigate your need for medical assistance.
I just double checked the numbers ad the US has more ICU/CCB beds/100,000 inhabitants than any other nation including those with socialized medicine. The closest to us is Germany where it is just about tied. So we do not want to compare our ability to provide care for seniors with that of Italy or most any other country with socialized medicine.
The US military including the National Guard should be mandated to start providing medical supplies and trained health care professionals to all civilian facilities that need them. They should immediately start constructing/setting up field hospitals in athletic stadiums, athletic fields, parking lots, vacant lots. Many troops are sitting around in the US not doing anything particularly useful. Let’s put them to work.
I so appreciate strong leaders such as yourself. We are in need of more! I have a concern. I feel the libraries should close. With schools closed as well as the YMCA, there will be more patrons in libraries. Ordinarily, that would be a good thing, but how can librarians keep people, particularly children, six feet apart? If the virus can live on surfaces for up to 72 hours, how can librarians keep the books from being conduits?
Thanks as ever, Will. I am convinced – I am urging everyone I know to encourage our governor to shut down all non-essential businesses. Yes it is disruptive. And yet as you note, with potential asymptomatic transmission, the scientists and epidemiologists and medical experts are saying waiting another day is irresponsible and will lead to more deaths. It is hard – I get it – it is a sunny day here in Cambridge, no one I personally know is confirmed sick. And yet, I might already have it. And others in my community definitely do. WE have tested fewer people than pretty much any other industrialized country – it is spreading.
I know that her in Cambridge officials – the mayor and city manager and public health officials and other city councillors – are working overtime to mitigate. France and Spain have gone into partial lockdowns – we will be next. They did not take the step lightly. We all have to spread the word as much as we can.
Thank you again for your very thoughtful post and your work on this issue. I am wondering why Governor Baker said it was okay for schools to stay open. That seems counter-intuitive to everything here. I personally would be made more at ease if Baker mandated a two-week “lockdown” where everyone was told to basically stay at home (in other words, except in extreme circumstances; except for those needed for critical jobs like healthcare workers, police, fire, etc; and except to go out to get food and medicine) and the National Guard was deployed to distribute food and medicine to those in need or check on those in need. It seems like it is better to have more extreme social distancing mandated now then to wait and have to do it later when more people are sick and the National Guard may be needed in other ways. Thoughts on why this isn’t happening now and why Baker isn’t mandating all schools, restaurants, gyms, bars, etc. in MA closed would be helpful.
Fortunately, just after you made this comment, the Governor rolled out a school closing order and limited bars and restaurants to take out. We may need to go further, but this is a big step.
Thanks for keeping us informed at the local level.
Thank you
Thanks so much for providing this information. You do a wonderful job of keeping your constituents –and others like me who have moved out of your district.
Keep well!
yvonne stapp
Thanks for sharing this information. I decided to leave Boston today to work remotely from my home on the Cape. I am fortunate to have a position that allows me the flexibility to work remotely.
Hi Will,
Thank you for continuing to keep all of us informed about the coronavirus. I feel we need to help each other during these uncertain times.
THANKS Will, you are the best.
I have a question regarding asymptomatic transmission. Droplets are the physical vector for exposure via inhalation. If one is asymptomatic, by definition, they are not coughing, sneezing. Yet, the are infecting others, apparently. I have not seem an explantion of this, as to how/is that mode of transmission. If they are pre-symptomatic (they later show typical symptoms), well *maybe* there’s a fudge factor. But, if they don’t (and i believe many didn’t), then how does it occur? It has to be surfacial contamination (hand to face), or…normal respiration??
No one knows the exact mechanism, but if a person has virus in their saliva, it can get around even if they aren’t coughing or sneezing. As a friend used to say to me when I stood too close and spoke too enthusiastically “just give me the news, not the weather.”
Thank you Will for all this information. I finally feel like someone is telling us what is really going on. You are a an amazing Senator. I only wish the President was as informed and articulate as you.
Fondly
Linda Ferrari
Will, the science is clear – we need the Governor to take more serious action now and not wait. We need to protect our healthcare workers and the most vulnerable. Please urge him to act now, with all haste, and ensure those who will be economically impacted that they will be made whole. So many people work multiple jobs and do not have the liberty to protect themselves without these assurances.
I concur.
Agree, and I wonder how those of us who are priveleged to work from home, who’ve been able to stock up on necessities (and have where to store them), etc. – in short, who have the resources and circumstances to weather this storm with some confidence – but who are avoiding contact, how we can best help the heroes of this crisis who are stocking shelves, delivering packages, taking care of homebound kids, staffing hospitals, etc., or just plain out of their necessary income.
Well done, thanks so much.
Pls accept this as my formal thank for your time and attention to such urgent matters.
It’s essential to learn and understand how any one of us could be spreading the coronavirus unknowingly. That is the implication of two key phrases that should be top of mind for everyone: “community spread” and “asymptomatic transmission.” and related matters.
I pray this shall pass soon.
P. G.
I find it outrageous that Baker ordered restaurants to not admit patrons except for take-out orders. If gatherings of up to 25 people are permitted, why can’t restaurants limit patronage to 25 at a time? This will devastate the food service industry and its workers, and make going out lunch at work a nightmare and perhaps even more hazardous. Workers will flock to markets to get lunch. Aren’t they even more at risk shopping in crowderd stores which may have many more than 25 customers plus staff than dining out? Baker’s order must be modified. It’s plumb crazy.
Kids are congregating on playgrounds. Patents are bringing small children to play on the gym equipment, even though the virus can live three days on those surfaces. Close the playgrounds! Parents need to be more vigilant with the “social distancing”.
Thank you very much for this round-up of information thus far. Very appreciated. Well done.
Thank you so much for this (and your other) level headed, thoroughly informed and well composed communications. Your balanced but decisive tone is good the nerves
(mine at least:). I hope many other people get to read your message, take a deep breath and feel calmly empowered to do what they can for each other.
I am not a doctor, but I do read quite a bit:
“Three Intravenous Vitamin C Research Studies Approved for Treating COVID-19,” by Andrew W. Saul, Editor
http://orthomolecular.org/resources/omns/v16n12.shtml
Do any of you take raw garlic at the first sign of a cold?
I do. It works.
Will,
Thank you so much for sharing this information. I have simulated the spread of a range of infectious diseases and the relative impact that different counter measures can make in flattening the peak of infections within a population. It is refreshing to see such a clear and well explained rationale for the strong actions being taken now in the Commonwealth. I hope and pray that citizens behave unselfishly and carry through on what is needed now to protect our most vulnerable people.
Thank you Mr. Brownsberger, that was very informative.
Thank you. Glad to see the Governor act, but I agree that even more steps may be needed. What about playgrounds? I saw lots of kids were playing at Joey’s Park in Belmont (and heard similar about PQ Park) this weekend, though that seems like a terrible idea. Shouldn’t the town be closing town playgrounds?
The Town of Arlington has closed public playgrounds.
The definition of social distancing which I’ve seen is more stringent than this order. I’ve read doctors arguing that it’s not okay to socialize at all even with a small group of friends. We should be better off if more stringent rules were put in place. It’s not clear to me whether access to banks would be ended, and if so, how to obtain food or pay bills? Will postal service also be curtailed? Also, I ordered a freezer to store food, and it is not due to be delivered till next week. Does this mean that I can’t receive deliveries and installation of an appliance? Should the idea of social distancing prohibit all of these things? For older people who have not gone online in bill paying or used the banks’ automated systems for payments, and who are not familiar with them (I am an example), a transition to all app or all online transactions will be challenging. In general, I support trying to mandate disease-mitigating behavior, although I don’t know how attuned to older people’s needs these mandates will be.
This stance is absolutely critical to stop further spread of the virus. As a physician, I can confidently say that the best treatment is prevention. Physicians were urging social distancing and other measures to flatten the curve much earlier in the game, but it was dismissed as paranoia. Community spread started a long-time ago and we as a collective are woefully under-prepared. Covid-19 numbers are low simply we do not have enough tests thus have had to ration testing.
I am especially appalled by the hoarding of supplies especially masks and sanitizer because it seriously jeopardizes the lives of frontline physicians, other healthcare providers, and vulnerable patients especially since there is an existing pre-covid-19 deficit of healthcare workers. Physician burnout was declared a public health crisis last year. As of yesterday, two ER physicians are in critical condition due to covid-19; it is unclear whether it was occupational transmission or community spread. One of the physicians complied at all times with protective procedures. This virus is dangerous and its full impact unknown. I urge everyone in MA to take it seriously, practice social distancing, and get information from credible sources (and no Tito’s Vodka is not effective hand sanitizer). Above all let us remain calm, not panic nor forget kindness.
Will, thank you for analysis and insights. Test. Test. Test. Lack of timely testing was a major public health failure. We now must work together to remedy this failure.
Just returned from a trip to the US Virgin Islands and feel like I landed on another planet!
This information has been very helpful in making me aware of what is needed to decrease the spread of the virus. Thank you.
Thank you. Your detailed and expedient communication helps all of us save lives.
Most of the new social distancing measures seem sensible. I do hope, though, that the state will not require us to stay locked in our houses. I have been walking outside on nearly deserted streets and in the woods. Exercise, fresh air, and sunshine all contribute to health and keeping our immune systems functioning. I see about one person and one dog about every twenty minutes; keeping a generous distance is easy. Sitting inside and eating high-salt, high-sugar shelf-stable snacks and canned food during an anxious period can make people less healthy.
Thank you. This is what we need. I am staying totally at home since I am vulnerable to lung ailments. No one comes in my house for awhile. This is serious for “us guys.”
I have heard several experts recommend going outside (keeping distance) as better than just staying inside.
I have a couple of questions.
First, today’s Boston Globe has an article about GameStop being open (last I heard, video game rentals aren’t considered an essential service), AND they are requiring employees to crack open the door while using a plastic bag to protect themselves.
This is horrendous.
Along a similar line, I have a daughter who works at a local Whole Foods. She tells me that although the clean the front of the store to give the appearance of pandemic cleaning practices, they are not doing this for employee restrooms and break rooms.
How can MA employees stay safe in these environments? I feel as though we are living with mine fields all around us, with the most vulnerable at risk.
Totally on the page that we need to do more for front-line workers.
The other thing I wanted to ask you, Senator, is this: some other states allow some online grocery purchases to be paid with SNAP food benefits. This would help tremendously to protect the most vulnerable – how can we make this happen?
My understanding is that change is in the pipeline.