It’s coming. When will it arrive in Memphis and Shelby County? How long will it last? How large will it be? How many people will get sick? How many will die? Will we be prepared?
Hundreds of people in government, health care, academia and business are working — literally around the clock — trying to predict and prepare for the coming COVID-19 surge.
That’s the date when local COVID-19 cases are expected to peak and most challenge the capacity of the local health care system.
One model, endorsed last week by Tennessee officials, opens in a new windowpredicts that the surge will hit hospitals across the state on April 19. The same model predicts the surge will hit America four days earlier.
“I want every American to be prepared for the hard days that lie ahead,” President Trump said last Wednesday, April 1. “This is going to be one of the roughest two or three weeks we’ve ever had in our country. We’re going to lose thousands of people.”
The next two or three weeks will be the roughest for Tennessee as well, according to the state’s forecast.
That model predicts that the number of hospital beds, ICU beds and ventilators needed statewide to treat local COVID-19 patients will exceed the number currently available by this Thursday — April 9.
But another model, being followed by local epidemiologists, predicts the surge will crash into Memphis-area hospitals in mid-May or possibly even later in summer.
Members of the Memphis and Shelby COVID-19 Task Force aren’t waiting to see which model is right.
Doug McGowen, the city’s chief operating officer, has asked the chief executive officers of the four local hospital systems to deliver early this week a coordinated plan to handle the surge.
The plan must explain how Baptist, Methodist-LeBonheur, St. Francis, and Regional One will work together to double the number of available hospital beds, triple the number of ICU beds, quadruple the number of ventilators, and find enough doctors, nurses and other medical personnel to staff the surge.
No one knows exactly how much space, equipment, medicine and medical personnel will be required to meet the surge.
No one knows how many people will be infected with the novel coronavirus, nor how many will die. Mortality estimates for Shelby County range from 250 to 20,000.
Nearly everyone agrees that the arrival, magnitude and duration of the surge — and ultimately the resulting number of deaths — still depend on a variety of biological, medical and sociological factors that can and likely will change.
That’s why hundreds of professionals still are working not only to predict and prepare for the COVID-19 surge, but to mitigate and manage it.
The goal remains to “flatten” the curve and spread out the number of COVID-19 cases so they don’t hit the health care system like a tsunami.
“No state, no metro area will be spared,” Dr. Deborah Birx, White House coronavirus response coordinator, said a week ago.
“And the sooner that we react and the sooner the states and the metro areas react and ensure that they put in full mitigation at the same time understanding exactly what their hospitals need, then we’ll be able to move forward together and protect the most Americans.”
Predicting the actual date of the surge in Memphis, or anywhere, is a complex calculation that depends on a number of ever-changing variables.
- The number of susceptible people in a particular area.
This coronavirus is a new or novel virus. There is no immunity or vaccine yet, so it’s assumed that everyone is susceptible.
- The number of infected people in that area.
That can change every day for three reasons. More people are being tested. More people are being infected. The number of people being infected is changing due to social distancing and other efforts to reduce the spread of the virus.
- The number of people who have recovered in that area.
That number is constantly changing. And the models presume that those who have recovered from COVID-19 are immune from subsequent infection.
Some models also presume that only a certain percentage (say 15 percent) of COVID-19 cases have been detected.
That’s because not everyone has or will be tested, and an unknown number of infected people don’t show symptoms and remain untested and undetected.
The models throw in several other variables:
- The best current estimates of how long someone is infectious (14 days).
- How many new cases each infected person causes (about 2.5).
- The percentage of COVID-19 patients who need to be hospitalized (5-10%).
- The percentage who need to be in an ICU (2-5%) and on a ventilator (1-2%).
- The length of stay for each patient that uses a bed, an ICU and a ventilator (7-14 days).
- All of those variables have made predicting any area’s surge a moving target.
It’s even more complicated than that. Local officials have been using opens in a new windowdifferent models to predict the surge.
A team of local epidemiologists, who study diseases, are using a model developed for individual hospitals by the Predictive Healthcare team at the University of Pennsylvania.
It’s called the COVID-19 Hospital Impact Model for Epidemics, or opens in a new windowCHIME.
It tries to calculate the impact of local social distancing measures, and estimate the percentage of noncompliance.
For example, it presumes that a community achieving 35 percent compliance will suffer more infections and deaths and sooner than a community achieving 65 percent compliance.
”People still can dictate how high the surge will be as well as the duration of the surge,” said Dr. Manoj Jain, an epidemiologist and infectious disease expert hired to advise the city on its coronavirus response.
”Social distancing works,” he said. “The more we do to slow and flatten the surge, the better we will be able to ride it out.”
City and county leaders had been relying on the CHIME model to help them prepare for the surge. That model predicts a later and lower surge in about a month.
But two weeks ago, Gov. Bill Lee asked Vanderbilt University to create a new model.
“I have asked for a modeling that is unique to our state,” opens in a new windowLee said on March 26, “and we think we’ll have that model within a day or so, having informed decisions around next steps.”
A day turned into a week as city and county officials waited for the new model to help them predict what they would be facing in the weeks ahead.
The state finally released its “new” model last Wednesday, April 1. It’s basically the model developed by the University of Washington’s Institute for Health Metrics and Evaluation, or IHME.
That’s the same model being used by the federal government to predict a national surge by April 15.
The Tennessee/ opens in a new windowIHME model predicts the surge will hit much sooner (April 19), and be much steeper, but be over in about a month.
The Hospital/CHIME model predicts the surge will hit much later (mid-May to early August), and last longer (until November), but won’t be nearly as steep or lethal.
Another big difference between the two models is more concerning to local officials.
The Tennessee/IHME model makes only state level predictions. Local epidemiologists haven’t been able to adjust that model for Memphis and Shelby County.
Neither model accounts for the likelihood that Shelby County’s health care system also will be taking care of COVID-19 patients from North Mississippi and East Arkansas.
“If the virus comes, which it will, and it strikes hard in rural west Tennessee and eastern Arkansas and north Mississippi, Memphis will feel it,” opens in a new windowU.S. Rep. Steve Cohen of Memphis said March 31.
“Those citizens will come to Memphis for health care since some of their counties do not have ventilators. That will put a crush on our hospitals.”
Local officials know they can’t stop the surge, but they can try to delay and lessen its impact.
That would give local hospitals more time to prepare for the surge and treat patients.
That also potentially could reduce the overall number of COVID-19 patients who will require medical care.
“If we don’t blunt the spread of the virus, we will soon be out of capacity at our local hospitals,” McGowen said last week.
That’s why officials last week put more pressure on nursing homes and assisted living facilities to protect, test, isolate and treat their highly vulnerable residents.
That’s why officials have been working to reduce the number of people in other high-density facilities such as the Shelby County Jail and local prisons.
That’s why they’ve been pushing for more testing — especially for health care workers — to identify and quarantine or isolate more of those who are infected.
That’s why they’ve been training more people to do contact tracing to identify more quickly people who have been in direct contact with those who are infected.
And that’s why they’ve been doubling-down in recent days on social distancing. The best way to avoid infection is to avoid people who have the virus.
Last Thursday, the county’s chief health officer opens in a new windowwarned that up to 20,000 people could die in Shelby County if stay-at-home orders and not strictly followed and enforced.
“This is serious,” said Dr. Bruce Randolph. “This is a life-and-death moment. The actions that we take now will make a difference in the number of deaths that occur as a result of COVID-19.”
Social distancing remains the task force’s top priority and greatest hope for slowing and weakening the surge.
Memphis started earlier than any other city in the state.
Local public schools closed for Spring Break March 16 and didn’t reopen. Neither did local colleges.
Mayor Jim Strickland opens in a new windowdeclared a civil emergency March 19, requiring restaurants to provide take-out or delivery only, closing bars and gyms, and asking that all worship services be postponed or moved online.
Local mobility declined 24 percent that week from the previous week, according to cell phone tracking opens in a new windowdata measured by Cuebiq. That wasn’t enough.
Local health officials think social contacts must be reduced by at least 65 percent to stop the spread of the virus.
On March 24, Strickland issued a “ opens in a new windowSafer at Home” order, requiring Memphians to stay home unless they are performing an “essential” task or service. The mayors of Shelby County and its six smaller cities did the same.
“We are in serious, unprecedented times,” Strickland said. “There has to be personal responsibility. You must take social distancing seriously.”
Local mobility declined only about 4 percent that week, according to Cuebiq. But last week it was down 32 percent from the previous week.
Other measures of social distancing also have been discouraging.
The Tennessee Department of Transportation has been opens in a new windowmeasuring freeway traffic now compared to a year ago.
Traffic on Memphis highways declined from March 13 to March 24, dropping to 30 percent of what it was a year ago. But over the past week, that decline stalled.
The first week of March, people in Shelby County traveled an average distance of 3.89 miles. That was down to 2.66 miles last week.
But residents of only 11 other stay-at-home counties in America are traveling farther, according to an opens in a new windowanalysis of Cuebiq data by The New York Times.
Gov. Bill Lee and state officials looked at cell phone data compiled by another company, opens in a new windowUnacast.
That company’s data showed that Shelby County residents reduced their average mobility 40-55 percent last month.
That’s about the same as the average American. But it’s far less than the 65 percent local health officials say is needed to contain the virus.
Last Thursday, Lee took the same direct and somber tone last week when he opens in a new windowordered all Tennesseans to stay home at least through April 14.
“I want to speak directly to every Tennessean,” Lee said. “The month of April stands to be a very tough time for our state. COVID-19 is an eminent threat and we need you to understand that staying home isn’t an option. It is a requirement for the swift defeat of COVID-19 in Tennessee.”
The traffic and cell phone data give local officials a glimpse of how well social distancing policies are working.
They want an even clearer local picture.
For more than two weeks, data scientists at the University of Memphis have been developing a social distancing app being called mContain.
The goal is to more closely and accurately measure social contacts in three ways:
- Use cell phone data to determine where groups of 10 or more people are gathered at any one time in Shelby County.
- Use cell phone data to determine how many people have come within 6 feet of someone else for 10 or more minutes in a 24-hour period in Shelby County.
- Use cell phone and health care data to detect and send a text alert to anyone who comes within 6 feet or another person who has tested positive for the coronavirus.
City and county lawyers have raised privacy concerns. So have hospital lawyers. But the app is expected to be released in stages this week and next.
Memphis and Shelby County have been mobilizing for the COVID-19 surge for nearly a month.
It’s a massive undertaking, a daunting logistical challenge, even in a community known worldwide for its logistics expertise.
It involves thousands of people working in multiple levels of government and at multiple health care facilities with varying levels of expertise, experience and responsibility.
It requires all of them to prepare in different ways for something they’ve never before encountered — a pandemic that also is effecting everyone around the world.
A virus that is more infectious than Ebola, and 10 times more lethal than the seasonal flu.
A virus that can remain viable in the air for up to three hours and on some surfaces for up to three days.
A virus that can be transmitted by carriers who are not showing any symptoms.
A serious and sometimes severe respiratory disease with severe complications can require more than two weeks of intensive care.
“This is a once-in-a-lifetime epidemic,” opens in a new windowsaid Alisa Haushalter, executive director of the Shelby County Health Department and one of the key leaders of the Memphis and Shelby County COVID-19 Task Force.
”It’s important for those of us who know that to say that so that people understand this is something very serious.”
Every morning at 8 a.m., dozens of people gather online to discuss what is being done — and what needs to be done — to contain and manage the pandemic here in the greater Memphis area.
The Memphis and Shelby County COVID-19 Task Force includes all county mayors, officials from bordering counties, and other local public officials.
It includes the CEO’s and COO’s of all major hospitals, leading epidemiologists and infectious disease experts such as Jain, and health care professionals from Church Health, Christ Community Health Services and other providers.
It includes Haushalter and other officials from the Shelby County Health Department, as well as officials representing local law enforcement, fire fighters and other first responders.
It includes public health experts and other scientists from UTHSC and U of M, and representatives of TEMA, the U.S. Army Corps of Engineers and other state and federal agencies.
Their top five priorities:
- Social distancing
- Contact tracing
- Quarantining or isolating
- Predicting and preparing for the surge.
“We’re working to ensure that not only the community remains safe, but members of the healthcare community remain safe as well, so that they can provide care,” said Dr. Keith Norman, a local pastor and vice president of government affairs with Baptist Memorial Health Care.
Over the past week, preparing for the surge has taken on the greatest urgency.
Even the most conservative forecasts suggest that Shelby County’s health care system will need:
- More space for more hospital beds.
The U.S. Army Corps of Engineers is building a temporary hospital that will provide 1,000 non-acute beds at Gateway Shopping Center on Jackson Avenue.
Officials believe they can squeeze in an extra 1,000 beds into existing hospitals.
If more beds are needed, other options include opening temporary facilities at the Fairgrounds, in other empty buildings or in large tents.
“Given at the rate that the peak may be coming, as soon as we identify the site for the alternative care, or the sites, we will begin the build-out,” McGowen said last week.
“We are not going to wait.”
- More ICU beds and ventilators.
ICU beds require adding more ventilators and monitors to regular rooms.
Tennessee heath officials have ordered 570 additional ventilators and plan to dole them out as needed across the state.
Hospitals also might use anesthesia ventilators and non-invasive CPAP and BiPAP machines when they are medically appropriate.
- More personal protective equipment, or PPEs, such as face masks, gloves and gowns.
The Memphis Medical Society and the health department have put out a call for donations from the public, especially those who work in construction, HVAC and dentistry and commonly use PPEs.
The University of Memphis, among other technology centers, has been using 3D equipment to produce 10,000 face shields.
More than 100 inmates at Tennessee Department of Correction facilities have volunteered to use donated materials to make masks and other PPEs.
Radians, a Memphis company that manufactures PPE’s, has donated more than 14,000 N95 masks.
“With a worldwide shortage of respirator masks, we knew this donation would quickly assist first responders and health care workers as they help Memphis rise above the COVID-19 crisis,” opens in a new windowRadians CEO Mike Tutor told the Daily Memphian.
- More health care workers — especially pulmonologists, respiratory therapists, anesthesiologists, surgeons and nurses.
Local hospitals have been postponing elective surgeries and taking other steps to reduce demands on doctors and nurses so they can handle COVID-19 cases.
Hospital officials are talking about doubling the normal number of patients per physician from 20 to 40.
Local officials are working with UTHSC to recruit residents and medical students to handle lower-level care.
State and local officials are recruiting previously furloughed and retired doctors, nurses and aides to come back to work to meet the surge.
Gov. Lee issued an order last month to make it easier for retired medical professionals to return to work.
The number of retired nurses seeking to renew their licenses tripled in March, said Tina Gerardi, Tennessee Nurses Association.
“What we’re preparing for is that worst-case scenario,” Lisa Piercey, commissioner of the state department of health, opens in a new windowexplained.
The worst-case scenario is that the surge isn’t delayed or flattened. That the number of people who get infected and need medical care overwhelms the hospital system.
That’s what happened in Italy. That’s what has happened in New York City.
“Then there becomes really serious ethical dilemmas,” Haushalter opens in a new windowtold the Daily Memphian last week. “If you have limited bed capacity, who gets that bed and who does not? Who gets that ventilator and who does not?”
This story first appeared at dailymemphian.com under an exclusive use agreement with The Institute. Photos reprinted with permission of The Daily Memphian.