Vermont could have 16 times more cases than officially reported .

Stanford Health Care-Stanford Hospital

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University of Vermont Medical Center Emergency Room Nurse Derek Laferriere, left, hands off a sample to Community Paramedic Randy Lanier during a demonstration at a drive-up testing site for the coronavirus at the Champlain Valley Expo in Essex Junction on Wednesday. Photo by Glenn Russell/VTDigger

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The first case of COVID-19 in Vermont was announced on March 7.

Eleven days later we have 19.

And that’s just the tip of the iceberg. It’s likely we now have as many as 16 times the number of infections being reported today, most with few symptoms. That means there could be nearly 300 infected residents in Vermont right now, experts say.

The reason we don’t have more precise estimates of how many people are sick in Vermont, or anywhere else in the United States, is because we aren’t testing enough people, according to Steve Goodman, a professor of epidemiology and population health at Stanford University.

“What’s happening is invisible because we only report someone as a case when we test for it,” Goodman said. “The numbers being reported are a function of how many tests we’re doing.”

Goodman says the 16 times multiplier is a rough, back-of-the-envelope hypothetical based on current knowledge of how the virus is spreading in other places. It assumes that one in four people who have COVID-19 are symptomatic enough to be tested, and that positive cases were infected one to two weeks prior, plus 3-4 days for testing and reporting. During that lag time, those four people can unwittingly spread the coronavirus to family, friends, co-workers and classmates, doubling the number of people who are infected every four to six days.

“So if we only test 1 in 4 infected persons, and the number of infected persons doubles twice before we hear about a case, that equals 16,” Goodman said. “That’s the math. It’s always shocking, but also completely predictable.”

The rate of infection estimates can vary widely. Jeffrey Shaman, a Columbia University environmental science professor, told the Boston Globe that only one in five infected people are symptomatic enough for testing. Another researcher, Samuel Scarpino, a Northeastern University professor who specializes in infectious disease modeling, told the Globe that the U.S. has identified only between 1 of every 10 cases and 1 in 30 cases.

While the experts are grappling with the numbers as the pandemic unfolds, what we do know is what we’ve seen play out in other places around the world. There is one case, then another soon after and pretty soon the number of cases is doubling every few days. This is what happened in Wuhan, China, and northern Italy, where tens of thousands of people got very sick and hundreds of people died, largely because the health care system was overwhelmed.

In a podcast interview with his brother David Goodman, a Vermont journalist, Steve Goodman said the U.S. is in a “true emergency here.” If the epidemic is unchecked and continues to double every four to six days, in two months we could see 1,000 times more cases than are currently being reported, he said. Today, the U.S. is reporting 5,881 cases. That means the total number could be higher than 5 million by June if we did nothing.

“This is an impending catastrophe,” Steve told his brother on WDEV’s The Vermont Conversation.

Because COVID-19 is so contagious, large population centers, including New York City, Boston, the San Francisco Bay area where Goodman lives, and even Burlington, are much more susceptible to higher infection rates. That’s why residents of Northern California have been ordered to “shelter in place,” and Burlington Mayor Miro Weinberger on Tuesday sent a message to city residents urging them to do the same.

“Once you’re in an exponential growth situation and notice what’s going on, it’s lost,” Goodman said.

Steve Goodman, professor of epidemiology and population health at Stanford University. Stanford photo

Unchecked, exponential growth can mean 20% to 70% of a population could contract the virus, scientists say. Governments in Britain and Germany are assuming 60% to 70% of their populations could become infected, according to the New York Times.

Checked by the kinds proactive, drastic measures taken by the Scott administration and Weinberger to curb community spread by banning gatherings of 50 or more people and keeping portions of the population at home — schoolchildren, state employees, restaurant patrons and workers — the rates of COVID-19 infection will fall and could be much, much lower, according to Goodman and Jan Carney, a University of Vermont epidemiology professor.

Goodman says moving early and aggressively to control the outbreak is vital. “What you’re doing is tough, and the population thinks it’s extreme,” Goodman says. “But even if we could stop new infections today, we wouldn’t see the effect for two to three weeks.”

Keeping people at home is the only thing that will slow the pandemic.

“If the social distancing is extreme enough, the infection rate can stabilize or even go down,” Goodman said.

Without these extreme measures, the infection rate could continue to double every four to six days.

Once there is a critical mass of cases, the numbers of infected individuals mushrooms rapidly. About 80% of people who contract the disease are asymptomatic or have mild symptoms that seem like the regular flu. The other 20% experience more significant symptoms — a high fever and dry cough — that in some can lead to respiratory distress, hospitalization and even death.

That’s why this virus is different, Goodman says. “It’s highly contagious,” much more so than the seasonal flu, which most people have some immunity to. The CDC is reporting 36 million flu cases so far this year, about 11% of the population.

“Right now, 100% of the country is susceptible to this virus,” Goodman says. “And it’s 5-10 times more fatal than the flu. That’s why people are scared.”

The overall COVID-19 mortality rate is roughly 0.5% to 1%, Goodman says, although in some areas it has been close to 2% or even 3%. It is much higher in adults over 60, although Goodman notes that we don’t know how much of that is due to age or to underlying conditions such as heart disease, lung disease and diabetes.

The way it manifests over time will be very regional, he said, and the nation needs “massive” testing capability to control the epidemic. “We don’t even have minimum testing right now,” Goodman said.

“It’s going to affect a lot more people, and we are testing effectively nobody,” Goodman said. “We have almost no idea how many people really have it.”

In Vermont, the health department says more than 600 people have been tested.

Nationally, 125 people per million have been tested in the U.S., according to the New York Times. South Korea is testing at a rate of 5,000 per million, 40 times higher.

Is the state ready?

The math is not only shocking, it’s also critically important for planning purposes to make sure what happened in Bergamo, Italy, doesn’t happen here.

Last week, COVID-19 patients overwhelmed the medical system in Bergamo. The hospitals didn’t have enough beds and patients were cared for in warehouses. Because they didn’t have enough ventilators to help people with severe — and fatal — respiratory distress, doctors were forced to decide who would live and who would die. About 2,100 people have died; more than 47,000 people have contracted the disease.

It is unclear whether Vermont is ready for a large outbreak of COVID-19.

Dr. Mark Levine, commissioner of the Vermont Department of Health, said Wednesday the state is relying on models that have been developed by national experts and is working on a statistical model “as we speak” that would help to put national statistics in local perspective.

“There’s no question that when we identified 19 cases in Vermont, that there are more than 19 cases in Vermont, that we haven’t fully identified,” Levine said. “What’s likely though, is that the majority of those other cases are not very ill, or they would have come to the attention of the health care system.”

Countries that have the lowest case fatality rates like South Korea have tested huge swaths of their population, Levine said, identifying mild and even asymptomatic cases.

Levine said the supply of test kit materials is limited and expensive. The department is currently looking at “10 or 12 pathways” and working with federal agencies to obtain more test kits, reagents, supplies and machinery.

The health department currently only has the capacity at the state health lab to test medical workers and people who have been recommended by a physician. Everyone else is being grouped into higher and lower categories.

Dr. Mark Levine, Vermont’s health commissioner, briefs reporters on the state’s preparations for coronavirus. Photo by Mike Dougherty/VTDigger
Dr. Mark Levine, Vermont’s health commissioner, briefs reporters on the state’s preparations for coronavirus last month. Photo by Mike Dougherty/VTDigger

“I think you’ll understand that those in the higher priority group might be in a hospital bed or an ICU bed,” Levine said. “They may be a health care worker who has to know if they can continue to work in the health care system.”

The commissioner said he doesn’t anticipate having the capacity to conduct “expansive health surveillance” that would help scientists understand the extent to which COVID-19 has spread. It’s still unclear how many would be needed for such an undertaking.

And it’s an open question whether the state has the capacity — even with social distancing policies in place — to deal with possible spikes in infection rates for the duration of a pandemic that could last for more than a year. According to a new report from the Trump administration, the pandemic could last 18 months.

Depending on how many people get sick over what period of time, the medical system may or may not have enough beds, intensive care units and ventilators to handle the caseload.

What we do know for certain is, Vermont has 1,300 hospital beds, 99 ICU units and 210 ventilators.

What we don’t know is how many people in Vermont could be infected over the next six to 18 months, exactly how many hospitalizations may be necessary, and how many patients would need intensive care and ventilators.

Dr. James Lawler, an infectious diseases specialist and public health expert at the University of Nebraska Medical Center, recently gave a presentation to the American Hospital Association that included “best guess” projections.

According to the New York Times, Lawler estimated that about 96 million Americans would be infected. About 5%, or 5 million people would need to be hospitalized. Of that number 2 million would need intensive care and 1 million would need ventilators.

Lawler confirmed in an email to VTDigger that a 30% infection rate in Vermont would result in 187,900 infections. About 9,400 people would need to be hospitalized over time, another 3,800 patients would need access to ICU beds and 1,900 would need ventilators.

Dr. James Lawler, infectious diseases specialist and public health expert at the University of Nebraska Medical Center. UNMC photo

The Times used Lawler’s analysis to calculate a 0.5% morbidity rate based on a 30% population infection rate. That pegs the total number of projected deaths at 480,000, a conservative estimate, Lawler says, that changes depending on the age group and health issues of different sectors of the population.

On Friday, a new report from the Imperial College of London, shows a fatality rate of 2%, or more than 2 million deaths in the U.S. if nothing is done to mitigate the progression of the pandemic.

In a statement, the authors of the report said “strategies to mitigate might the epidemic might halve deaths and reduce peak health care demands by two-thirds, but that will not be enough to prevent health systems being overwhelmed.” Best case, a vaccine could be available in 18 months.

“More intensive, and socially disruptive interventions will therefore be required to suppress transmission to low levels,” the authors wrote. “It is likely such measures – most notably, large scale social distancing – will need to be in place for many months, perhaps until a vaccine becomes available.”

Fatality rates climb for older people and people with underlying conditions, according to the CDC. Diabetes patients have a 7% morbidity rate. The death rate for people with cardiovascular disease is 10%, according to Statnews.com. Those over the age of 80 face a 14% fatality rate.

Even with a moderate infection rate — where 30% of the country gets infected, and the disease has a 0.5% fatality rate — deaths would surpass those from Alzheimer’s, strokes and diabetes to become the third-highest killer of Americans in 2020, according to an analysis by The New York Times.

It’s unclear whether the Scott administration is prepared for similar scenarios. The Vermont Health Department and the emergency operations center did not provide information about what COVID-19 infection rate levels they are using in their emergency preparations or the anticipated need for ventilators, ICU beds and hospitalizations.

Rebecca Kelley, spokesperson for the Scott administration, said in an email that the governor’s “entire strategy is oriented towards avoiding these types of stresses on the system and the work is being done across the Health and State Emergency Operation Center teams to carefully track these issues, as well as working to increase capacity of the health care system where needed.”

The New York Times reported Tuesday that the state of New York could face a severe shortage of ventilators for patients. About 18,000 ventilators could be medically necessary; the state has 2,217 in stock.

On Tuesday, President Donald Trump told governors who are alarmed by the shortage of respirators that they should purchase ventilators on their own in the open market. Vermont Gov. Phil Scott was on that call and in a press conference Wednesday declined to comment on the president’s remarks.

Ventilators might not be the only equipment in short supply. A COVID-19 planning analysis released Friday by the Trump administration estimates the U.S. pandemic could last 18 months and result in shortages of medical supplies, staffing, personal protective equipment and diagnostics.

A VTDigger analysis of hospitalization and ICU data, based on ProPublica and Harvard Global Health data, shows how many hospital beds in northern and southern Vermont would be needed, depending on the percentage of people who are infected, over a period of six to 18 months. If the infection rate is 20% or below and stretches out over a longer period, it’s likely Vermont hospitals would have enough beds. If there is a spike in infection rates, and the cases are concentrated in a short period, the system could be overwhelmed.

The Harvard Global Health study also shows ICU beds would also be at risk for overload under a high infection scenario. The data from ProPublica shows there are 117 ICU beds in the Burlington area, including Champlain Valley and northern Vermont, and 105 beds in Southern Vermont, including Dartmouth-Hitchcock Medical Center, which is located in Lebanon, New Hampshire, and serves Vermont and New Hampshire patients.

In contrast, researchers estimate that the Burlington region would have 5,000 to 14,000 ICU patients over the entire course of the outbreak, depending on the infection rate. The Lebanon, New Hampshire, area would have 3,000 to 9,000 ICU patients. How much those patients overload ICU departments depends on whether the patients come in slowly over time or all at once.

Vermont could face a similar dilemma with 210 ventilators on hand, and the potential need for hundreds more. One estimate from a University of Nebraska-Lincoln researcher suggests that half of ICU patients will need ventilators — meaning about 2,500 to 7,000 ventilators for the Burlington region and 1,500-4,500 ventilators for the Lebanon, New Hampshire, region.

A national study of hospital bed and ICU access published by the New York Times and ProPublica can be found here.

A reason for hope

Jan Carney, the UVM epidemiology professor, says Scott’s rapid-fire response to the pandemic should give Vermonters reason to hope that the state could escape a meteoric rise in COVID-19 cases and avoid the tragic circumstances that have led to deaths in places like Bergamo, Italy.

Like many of governors around the country, Scott has taken draconian measures in the past week to curtail the threat of a spike of COVID-19 cases. Whether the executive orders came quickly enough is a question that will be answered in the weeks and months to come.

“We all have to do our part to slow it down, to protect the ill and older Vermonters who are at risk,” Scott said Friday.

“This is the lesson from other countries like China and Italy, where efforts to slow the spread were not implemented early enough and now we see them struggling,” he added. “It hasn’t hit us yet, but it’s only a matter of time before it does and we feel we’re positioning ourselves well to mitigate this in the future.”

Six days after the first Vermont resident tested positive for COVID-19, Scott called a state of emergency last Friday banning public gatherings of more than 250 people through April 15.

On Sunday, he closed schools through April 6 and agreed to allow state workers to telecommute. The next day, Scott announced a ban on gatherings of more than 50 people and shut down bars and eateries effective Tuesday afternoon. Child care centers were closed yesterday.

Jan Carney, associate dean for public health at the University of Vermont. UVM photo

Anyone who has traveled to Europe or Asia has been asked to self-quarantine and report to the Vermont Department of Health. Many businesses issued memos to employees last week, urging them to telecommute. Ski areas shut down on Sunday. And Darn Tough, a sock manufacturer in Northfield, was among a number of businesses that announced yesterday it will suspend operations for two weeks.

The governor has held four press conferences in just six days, even as the news has turned grim with additional new cases of the coronavirus being identified nearly every day. In the past few days there has been a jump in cases, bringing the total to 19.

The lack of clear direction and support from the federal government for testing, supplies and ventilators were in large part why he ordered public health restrictions this past week.

In his most recent speech, Scott emphasized that “this is a moment of service for all of us — from those working on the frontlines in health care to those who are simply following our social distancing guidance to protect others.

“We’re all in this together, and we will get through it,” Scott said. “Just like during Irene we are facing new challenges every single day. And I know, some are feeling scared. Worried and overwhelmed. Just like after Irene. We made it through. And we’ll do it again. We help our neighbors, we answer the call of duty. And we get creative to solve the problem.”

The governor urged people to stay away from one another, take precautions and just assume they have COVID-19.

“I’m not trying to create panic,” Scott said. “I’m just saying. Keep your distance, make sure you’re doing the right things and you’re not impacting others because you may be OK. But you may be harming someone else.”

Today, there is no traffic on the roads. Parking lots in city centers are eerily empty. Many workers are at home, telecommuting, if they’re lucky. The not-so-lucky have been laid off or put on furlough. Some grocery store shelves are bare. Schoolchildren are home and many people are hunkered down in their homes.

Carney says that’s what it takes to flatten the curve. Vermont has put the right steps in place to effectively mitigate the COVID-19 crisis, she said.

“If we apply the science, it can work, it will be effective,” Carney said. “If we do this consistently in the whole state, shutting down for a period of time can have a rapid, dramatic effect.”

Click here to check out a Washington Post graphic that shows how COVID-19 spreads and how social distancing can prevent a spike in cases.

Editor’s note: VTDigger data reporter Erin Petenko contributed to this story.

CORRECTION: COVID-19 is five to 10 times more fatal than the flu, not Spanish influenza.

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