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Social distancing during the COVID-19 pandemic: Staying home save lives

Published:April 02, 2020DOI:https://doi.org/10.1016/j.ajem.2020.03.063
      The severity of the COVID-19 outbreak is the greatest public health threat caused by a respiratory virus since 1918. According to the Imperial College, 2.2 million Americans could die if we do not mitigate the spread of infection [

      Ferguson N, Laydon D, Nedjati-Gilani G, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College of London doi:10.25561/77482

      ]. With the incidence of COVID-19 increasing, it may only be time before the healthcare system becomes overwhelmed and forces physicians to triage treatment among critically ill patients. Without an intervention, it is likely that there will be more seriously ill people than we have the resources to care for [

      Ferguson N, Laydon D, Nedjati-Gilani G, et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand. Imperial College of London doi:10.25561/77482

      ].
      The rate of COVID-19 infection is largely determined by its reproductive number (R0)-the number of secondary infections produced by an infected person. If the R0 is >1, infections will continue to spread. If R0 is ≤1 the infection will eventually diminish. The R0 of COVID-19 is estimated at 1.3–6.5, with an average of 3.3 [
      • Liu Ying
      • Gayle Albert A.
      • Wilder-Smith Annelies
      • Rocklöv Joacim
      The reproductive number of COVID-19 is higher compared to SARS coronavirus.
      ]. R0 is affected by a number of factors including the innate properties of the virus, and the amount/duration of contact people have with each other [
      • Delamater P.L.
      • Street E.J.
      • Leslie T.F.
      • et al.
      Complexity of the basic reproduction number (R0).
      ]. Although we cannot influence biological properties of the virus, we can change the amount of contact we have with each other via a phenomenon known as social distancing.
      Social distancing is the practice of increasing the space between people in order to decrease the chance of spreading illness. According to the CDC, spacing of 6 ft away decreases the spread of COVID-19 [
      Transmission of Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention.
      ]. Individual actions include working remotely, avoiding public transportation, and staying home if you suspect you have been exposed and/or are symptomatic [
      Personal NPIs: everyday preventative actions. Center for Disease Control and Prevention.
      ]. Community-wide measures include transition to online teaching, businesses temporarily closing, and the widespread engagement of telecommunication [
      Community NPIs: everyday preventative actions. Center for Disease Control and Prevention.
      ]. Multiple states including Washington state, California, and New York are resorting to statewide home orders being issued to minimize contact [
      Inslee announces “Stay Home, Stay Healthy” order. Governor Jay Inslee.
      ,
      Governor Cuomo signs the ‘New York State on PAUSE’ Executive Order. Governor Andrew M. Cuomo.
      ,
      California Sof. Governor Gavin Newsom issues Stay at Home order. Office of Governor Gavin Newsom.
      ]. Nationwide measures taken to minimize contact with potentially infected individuals include cancelling travel from China and Europe [
      Proclamation-suspension of entry as immigrants and nonimmigrants of certain additional persons who pose a risk of transmitting 2019 Novel Coronavirus. The White House.
      ]. It is likely that additional action will be taken with suspension of domestic air travel on the list.
      According to a large study performed in China, younger individuals are more likely to be asymptomatic when infected and could be unaware they are putting others at risk [
      • Dong Y.
      • Mo X.
      • Hu Y.
      • et al.
      Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China [published online ahead of print, 2020 Mar 16].
      ]. Of noteworthy importance is the risk of transmitting infection to the elderly, particularly those over the age of 60 [
      Severe outcomes among patients with coronavirus disease 2019 (COVID-19) – United States, February 12–March 16, 2020.
      ]. The severity of illness is much more dire in this population with a strong association between in-hospital death and older age [
      • Zhou F.
      • Yu T.
      • Du R.
      • et al.
      Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
      ]. For this reason, it is essential that contact is limited not only to ensure personal safety, but also to prevent the spread of disease to others who are at high risk for developing severe complications.
      Social distancing also plays a role in lessening the burden imposed on the healthcare system. In the absence of any intervention, there would be a rapid rise in the number of cases that could overwhelm the healthcare system's capacity, and force physicians to treat some patients over others. If 200,000 people became critically ill in the same week, it would overwhelm the <100,000 ICU beds [
      Fast Facts on U.S. Hospitals, 2020. American Hospital Association.
      ]. Moreover, it is likely that many of these patients would require a full-feature ventilator, exceeding the 62,000 available [
      • Rubinson L.
      • Vaughn F.
      • Nelson S.
      • et al.
      Mechanical ventilators in US acute care hospitals.
      ]. On the other hand, if this same situation occurred over the course of several weeks, it would be more manageable. Social distancing has the potential to slow the rate of infection and reduce the peak of incidence, and then fewer critically ill patients would need care on any one day. The peak incidence could be reduced to a level the healthcare system is equipped to adequately respond to and save thousands of lives that would otherwise be left without treatment.
      Delaying the peak to a later time-period could be beneficial. Delaying the peak incidence to the summer holds potential for healthcare facilities to dedicate more resources to those ill with COVID-19. Many of the resources used for serious cases of influenza are also required for severe cases of COVID-19 and stalling the peak incidence of cases to the summer when the majority of influenza cases have resolved may lend more resources to these patients. In the end, this improves the healthcare system's ability to treat those in critical condition without the need to ration.
      It is too late to stop COVID-19; the importance of slowing the infection cannot be understated. With the vast amount of cases identified in the US, resources are becoming scarce. Concern in public health has often been about the shortage of physicians- rarely do we consider if a ventilator will be available if you become critically ill. Social distancing is a realistic solution that all individuals can take part in to reduce the risk of infection while increasing available resources to critically ill patients, during this pandemic.
      We can still practice physical distancing while remaining connected socially, emotionally, and spiritually. We can do this together to defeat the COVID19 pandemic and continue moving forward towards a brighter future for our current and future generations.

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