Next waves: Italy; Spain; U.K.; France?

The Quarantine Zone
1

Let’s start with the fact that despite big plans none of Italy, Spain, or the U.K. have blanketed contact tracing and isolation of contacts in place.

All have had over 400 deaths/million (up to 580 in Spain) and all are down to a rolling average of 3 to 6.5 new deaths/million currently (each having peaked at 13 to 20).

Among them some may yet be able to roll out more extensive contact tracing and isolation protocols, but they each have been starting to relax their restrictions without such in place. For the sake of this discussion let’s accept a hypothetical that contact tracing in large numbers continues to elude them.

Italy has, as of May 4, opened up parks, factories and building sites, and allowed families to visit each other in limited numbers. Funerals up to 15 are allowed as is regional travel with free movement as of June1 planned. Also as of June 1 “[h]airdressers, beauty salons, bars and restaurants are expected to reopen for dine-in service.”

Spain is easing into it. People are allowed out for exercise in shifts and “**usinesses that operate by appointment, such as hairdressers, will be allowed to open from Monday [now past].” Next was to be bars and restaurants.

The U.K. is also gradually relaxing their restrictions.

France is opening up shops and primary schools.

There seems no question to me that there will be some rise in new cases and deaths as restrictions are lifted, but as bad as it would have been to have not had these restrictions before? Will, without extensive contact tracing and enforced isolation of contacts, they have second waves that overwhelm their systems?

If not why not? What has changed that prevents such from occurring?

If, and it is an if, they maintain new case, hospitalization, ICU usage, and death rates in roughly the same lower but nonzero ranges they are now, without extremely extensive contact tracing and isolation procedures implemented, what does it imply?
Conversely … there are some nations that have succeeded in keeping cases and deaths very low. They were successful in confining cases on entry from becoming widespread, and have been maintaining such with a combination of travel restrictions, variations of degrees of “lockdown”, and extensive contact tracing with isolation of contacts. That model has been celebrated by many and by some described as having achieved eradication. Yet in some as second waves have begun to flare with any movement away from restrictions. And apparently “second waves are proving even harder to trace”. Will they both be able to avoid significant additional waves and allow any meaningful restrictions reductions? Or do they maintain restrictions depending on a vaccine to appear and be their one path forward?

2

I think Iran is already experiencing some sort of a second wave. Or maybe they only increased the test numbers so it looks like a second wave. I am not sure.

3

Re contact tracing, above a certain level of spread (IIRC 500 new cases a day) its not feasible using regular methods tp track and trace. As you are no doubt aware. Technology can help here, but it seems to go against Europes current religion, privacy. Apps have been postulated but whether they are effective is anyone’s guess and many experts I have read suggest no.

Which means there are going to be two types of countries, i) those whose intelligence agencies have been called to help with the tracking using cellphone tracking and ii) those whose are doing so while denying. The Euros are likely to be in group 2.

4

For the sake of discussion let us not assume covert tracing with operatives coming to your door instructing you to isolate yourself without telling you how they determined you had been exposed.

I’ll even further presume for the sake of discussion that in many countries a majority of people would willingly give up privacy in return for a promise that it would make them safer.

5

The first wave hit with no restrictions at all in place. There were soccer games, concerts, movies, people packed into mass transit, jam-packed bars and restaurants, and all the things that until three months ago were known as “normal life”.

Even after June 1, nobody anywhere will be back to anything resembling that. So I’d be shocked if the second wave is anywhere near as catastrophic as the first.

6

Contract tracing apps do not have to violate privacy, but it does require a large percentage of people to use the app and check in with a tracing server. 3Blue1Brown: “Contract Tracing and Privacy Protection”. But if the virus is capable of aerosol spread and there are a large number of asymptomatic carriers in the population, even an automated track and trace system is still going to be overwhelmed just by the number of possible duplicate contacts unless there is a lot of antigen testing to prevent spread. Track & trace works to keep a contagion from growing to epidemic proportions, but if it is already at epidemic levels it is essentially closing the barn door after the horses have run.

The first wave started from a small number of index cases that entered the country and spread from there. Now, despite reductions in new infections and new deaths, there is a large number of current carriers, many of which are asymptomatic or pre-symptomatic which will now circulate in the population. That means with the same rate of replication in the population the virus spread wider because it is represented in a broad segment of the population rather than starting from just a handful of index cases. People may modify their behavior to come into contact with fewer people or in a way that is less prone to transmit the virus, reducing the replication rate, but the second wave is going to start with a much larger number of carriers. The one advantage is that health authorities are now going to know to look for signs and respond quickly, which may ameliorate the spread but with a ~two week lag period there is still an opportunity for a massive number of new infections to occur, so how much of a peak occurs really depends on just how much and how many people modify their behavior to avoid transmitting the virus.

Stranger

7

For the sake of simplicity let’s even ignore Stranger’s cogent point that from here any next wave starts widely seeded in those countries.

Freddy, would the new levels have done the job enough in the first place then? If not why not if they’d work now? What has changed?

8

The first wave started from a small number of index cases, but it didn’t end there. Italy went into lockdown on March 9. The number of active carriers on that date would include (a) people who had tested positive within the previous 7-10 days and were still contagious; (b) people who would test positive in the next 7-14 days, because they were already infected and didn’t know it; and (c) people who were infected but never tested; we can only guess at the ratio of (c) to (a) and (b) but anecdotal evidence seems to indicate that the ratio is large.

The same three categories will apply to the “second wave” starting on June 1. We don’t know how large (a) and (b) will be on that date, but we can make an educated guess by looking at Italy’s case count per day (running about 1,000 per day as of today and slowly declining) and assuming nothing unusual will happen between now and June 1. The total of (a) and (b) will almost certainly be smaller on June 1 than it was on March 9. And as for group (c), the ratio of untested to tested cases, logically, has to be lower today than it was in March, because more people are being tested.

The point I’m trying to make, is that I believe that, during the final days of “anything goes” in early March (large public gatherings, crowded bars, etc.) the virus was spreading from a larger base than that from which it will be spreading in June. And the reproduction rate, while it will inevitably go up as lockdown is eased. won’t go back to anywhere near the “anything goes” rate. The combination of a smaller base and lower R, and of course a more prepared health care system, makes me optimistic that the “second wave” won’t overwhelm that system as the first wave did.

9

In Spain the only area which got overwhelmed was Madrid, which along with Barcelona is not easing restrictions yet.

10

In Spain the only area which got overwhelmed was Madrid, which along with Barcelona is not easing restrictions yet. The few people not wearing facemasks are the same ones which previously racked up police notices (or however you say denuncias in English), most of the companies which have had people working from home continue to have the same workers working from home (but in case any don’t, there’s already a petition to reinforce the current “recommendation” to do so)… There are people who meet with their relatives staying several meters apart. For example, the daughter of one of my neighbors works in the ICU: they met, but with the mother staying inside her house and the daughter outside, as far apart as the architecture of the building allowed (I’ve measured it and it’s almost 5m).

For us, buildings containing nothing but offices are extremely rare, but they tend to belong to large corporations (they’re not rented out in pieces), many of which already allowed some WFH before and are already changing their rules to allow it more. The change in the landscape for downtown areas is probably not going to be as large as it can get in the US, but some of those signature buildings fully occupied by a single corporation could end up becoming mixed-use ones (offices and housing): https://www.nytimes.com/2020/05/12/nyregion/coronavirus-work-from-home.html

11

My only experience is Canadian. Our government is being cautious. Our ICUs and hospitals all had spare capacity in the first wave as surgeries were postponed and routine visits much diminished. I personally do not think the second wave will be as bad, outside of nursing homes. Even with surgeries and return to normalcy, our system can cope. And our government is being more cautious with dentists, haircuts, malls and schools than most. I don’t see vaccines coming soon and am unaware of strong evidence of mutations. Should there be a rise in hospitalized cases, and of course there will be, our government would likely slow things down further. I think New Zealand is taking a sensible approach.

It still is not clear to me why the rates in Italy, Spain, Belgium and the UK were so high. Presumably they are opening up things in stages to mitigate unexpected surges. I do not think warm weather by itself will help much. But I do not think the second wave will be quite as bad. A lot of places made secondary Covid hospitals that they didn’t use, even London. And one presumes ventilators and PPE are more widely available and used. It seems to be more commonplace sedatives and nebulizers that are sometimes in short supply.

12

Personally, I’m not going to make any guestimates at what infection rates will look like in Spain and Italy after lockdowns end but I will note that while the governments of those countries were dilatory in applying isolation measures, once they did the populace demonstrated a high degree of compliance which is why they were able to bring those outbreaks under as much control as they have, so at least people in those countries are cognizant of the need to follow the direction of health authorities. I contrast this with the United States, where we have armed protesters besieging the legislatures in several states and nearly all of the states announcing the easing of isolation measures not actually meeting the CDC criteria of showing a reduction in new cases for two weeks.

Stranger

13

I think these are some of the most important questions to ask. To what end do we lockdown? I am honestly not sure how testing/tracing will work with this degree of community spread, nor can I imagine how long it will take to get the public health infrastructure to administer tests, run tests, inform patients of results, determine all relevant contacts of patients and inform them of the need to quarantine and/or test. That is a massive undertaking. Also what constitutes a “contact”?

Let’s say we open things up, and cases spike (which they probably will unless weather is a hugely mitigating factor, or unless this virus attenuates significantly for other reasons). Then we lock down again. Then what? Probably open up again, and cases spike.

The only end I really see to this is:

  1. herd immunity, through vaccination or transmission
  2. very effective treatments that can be administered early in the disease, or even prophylactically.

But I’d be really interested in hearing other people’s thoughts on this question.

14

Also, I’d like to add that keeping infections at a low enough rate to not overwhelm the healthcare system is important as well, although we likely also have increased that capacity to some extent in the past several weeks (ventilators, PPE).

15

It may depend, in part, by what one means by “larger”. A larger number of people infected is one thing, but a more geographically dispersed set of infected is another. A smaller count of people, but wider and more diffuse dispersion would likely mean a worse second wave. Time has allowed a greater dispersion through the land.