The pandemic is beginning to surge in Maine, as it is in New England. The good news is it is surging later here than elsewhere, and as a result, there are some lessons we can learn from our neighbors.

Take Vermont. It has a population size that is half of Maine’s. As of yesterday, they have 256 people who have tested positive, not far from our 253. But unlike us, they have lost 12 people to this disease, compared with Maine that has lost three.

A closer look shows that eight of them were patients at Burlington Health and Rehab, a 120-bed skilled nursing facility, where more than a dozen patients and staff have tested positive. We know from the experience in Kirkland, Washington, and elsewhere that people living in long term care facilities such as nursing homes are at high-risk for severe disease. So, while it is incredibly difficult for Mainers who live in such facilities and for families who are unable to visit, Vermont’s experience is a reminder of the critical importance of “cocooning” those who are at highest risk.

One major challenge is to make sure social distancing – this cocooning — does not necessarily mean social isolation, and hopefully we can figure out ways to reach out to those who are physically isolated, whether they’re in a high-risk group in a long-term care facility or isolated at home.

Then there is Massachusetts. The pandemic got a catalytic start there with what is called a super-spreading event. A two-day Biogen company leadership meeting at the Boston Marriott Long Wharf attended by 175 at the end of February resulted in at least 99 coronavirus cases in Massachusetts as well as a number in other countries and states, including five in North Carolina and several in Indiana, New Jersey, Tennessee, D.C. and even in Europe. For the first two weeks, they accounted for the vast majority of the Massachusetts’ cases.

Another New England super-spreading event was a 40th birthday party for a woman March 5 in Westport, Connecticut. Twentytwo of the 50 attendees became positive.

It is not well understood why some events can result in such disease transmission. It may be that one attendee who is socially gregarious happens to be highly contagious at the time of the event, but not ill enough to stay home. In some diseases, there can be silent (i.e. healthy) carriers who can transmit the disease.

Mary Mallon, also known as Typhoid Mary, is the most famous example of such a person. She was a healthy longtime carrier of typhoid, and especially because she worked as a cook, she managed to transmit it to hundreds of others over a period of years. Unlike COVID-19, typhoid is primarily transmitted through the fecal-oral route, something I’ll spare the details of in case you happen to be eating, but Wikipedia has a good explanation.

With COVID-19, we don’t know the extent to which people without symptoms may play a role in transmitting the disease. However, several recent studies indicate this may be significant. Although people are likely to be much more contagious once they have a fever and cough, people incubating the infection are much more likely to be engaging with others, and therefore may be major transmitters of it.

One study indicated that people without symptoms may have been responsible for 86% of the spread of the disease in China before the country was locked down.

Another study of two small outbreaks in China and Singapore indicate that about half of the people sick with COVID-19 in these two outbreaks may have contracted it from someone without symptoms. Complicating matters is COVID-19’s relatively long incubation period (time from exposure to showing symptoms) of an average of five days, and preliminary data showing people could be contagious for two to three days before they have symptoms.

Regardless, these super-spreading events in Massachusetts and Connecticut, combined with preliminary studies showing increasing evidence for disease transmission from people without symptoms, reinforce the importance of social distancing and vigilant respiratory hygiene. One never knows what events can be super spreaders or who may be silently carrying an infection.

Throughout this pandemic, I’ve stayed in touch with colleagues who work in hospitals in Massachusetts. Because the epidemic there is about one to two weeks ahead of us, their stories have helped to give an idea of what life may be like here in the coming days.

For instance, one friend who works in a large urban Massachusetts hospital, told me that as of late last week, most of their patients being admitted are now those diagnosed with COVID-19. Every several days they open up a new unit for just COVID-19 patients. They’re able to do that since they canceled all elective surgeries and admissions about three weeks ago, so they started the pandemic surge with a number of empty beds.

Maine hospitals likewise cancelled such admissions almost two weeks ago, and our hospitals in southern Maine have begun to create units for COVID-19 patients. The same Massachusetts colleague also shared that they’ve been astounded how few other people are being admitted to the hospital. But then he observed that if people are not driving much and they’re at home most of the time, and even walking outdoors more, perhaps they’re not in car crashes, they’re not having heart attacks, and their diabetes is better controlled. And maybe there is less air pollution that is also helping those with asthma and other chronic lung or heart disease.

If this is true, that social distancing measures are keeping others physically healthier and out of the hospital, preliminary experiences here in the U.S. tells us that is a very good thing since patients hospitalized with COVID-19 seem to be hospitalized for a relatively long time, and that is one reason why hospitals in outbreak areas are filling up. While an average length of stay for someone hospitalized in the U.S. is about 5 days, very preliminary data indicate patients with COVID-19 seem to be hospitalized for about twice that length of time, including a high proportion of them being admitted to ICU level of care. One case series shows for those admitted to the ICU, the average length of stay there is 12 days.

Once patients are ready for discharge from the hospital, a significant proportion seem to need nursing home level of care before going home. Yet, because of the severe impact this disease has on those living in nursing homes, and because of some data indicating patients who were severely ill with COVID-19 may shed the virus for days, many nursing homes are understandably reluctant to take COVID-19 patients.

In Massachusetts and other places, some are making plans for COVID-19 specific nursing home units so these patients have a place to go, which not only helps those patients make their way home, but also frees up hospital beds for those needing to be admitted.

A friend at Massachusetts General Hospital (MGH) in Boston said the hospital had purchased about 1,000 iPads when this started, and how that has been an excellent investment in ways they least expected. He said the original idea was to help break down the social barriers for people who are isolated due to COVID-19.

However, with high initial rates of health care workers getting exposed, they started using the iPads creatively to reduce such exposures. For instance, now both the patients and the nurses outside of the patients’ rooms have iPads, and they are able to communicate more frequently in such a way that reduces the use of PPE and reduces the chances of exposure of the nurses to the infection. Instead of large teams of 10 – 20 rounding on patients in the COVID-19 hospital units, they limit those who are physically rounding to two, who take the rest of the team along with them via their iPads.

MGH’s own Atul Gawande, renown surgeon and author, published an article March 21 in the New Yorker, with lessons learned from the COVID-19 pandemic in Singapore and Hong Kong. One observation he shared was on the likely reduction in health care worker infection with COVID-19 by simply masking everyone who works in a hospital. Although this was not published in a standard peer reviewed journal, his data and stories were compelling enough that my guess is this article led to the quickest change in medical practice of any article.

By March 23, MGH implemented universal masking of all employees. By March 27, MaineHealth did as well. I’ve heard of other hospitals following suit. Still others have expressed a desire to do this, but are constrained by supplies. Even MGH and MaineHealth have had to scramble to find ways of purchasing masks, mostly at much higher prices than normal (e.g. 10 times normal pricing). But with Maine CDC reporting yesterday that at least 43 health care workers in Maine have tested positive, and with us being early in this pandemic, we need to do what we can to be able to treat patients, and that also means protecting health care workers.

So far, the lessons we are learning from other states are mostly focused on their urban centers. There is understandably a great deal of attention on our cities, where because of high population density, infectious diseases can spread very quickly (New York City has a population density of 70,000 per square mile, versus Maine’s 43 per square mile; yes, that’s 43, not 43,000).

However, it is a mistake to think that rural areas are immune from this pandemic. For instance, during the 1918 influenza pandemic in Maine, the counties with the highest death rates were, in descending order, Aroostook, Piscataquis, Knox, Cumberland, and Washington. It appears that high population densities in Portland (Cumberland County) of many young recent immigrants (unlike COVID-19, the 1918 influenza epidemic hit young adults the hardest) and the densely populated wartime shipyards in both the Knox County area (Rockland and Camden) and northern Cumberland County (Brunswick and neighboring Bath in Sagadahoc County) were factors leading to their tragically high death rates.

Aroostook, Piscataquis, and Washington counties were primarily very rural farming, logging, and fishing areas of the state. A review I did of old newspaper articles from the time period indicated that a lack of health care facilities and poverty contributed to the high impact of the pandemic in these rural areas.

Similar risk factors exist today. Our urban areas have the vast majority of our hospital beds and intensive care units. People living in our rural areas are older, more likely to live in poverty, and therefore more likely to be in poor health — risk factors for more severe disease with COVID-19.

This haunting quote from the Aroostook County Madawaska newspaper from Nov. 18, 1918, describes the scene there: “La main de Dieu s’est abattue sur notre population… Jamais un pareil fleau a visite notre pays.” (“The hand of God has struck our population. Never has such a calamity visited our region.”)

The lessons from 1918 as well as from our neighboring New England states in 2020 should serve as a reminder that social distancing and respiratory hygiene are as critical throughout Maine as they are in New York City. And fortunately, Maine’s health systems are much more advanced and interconnected than in 1918.

MaineHealth and other health systems (Northern Light Healthcare, MaineGeneral, Central Maine Health Care), our federally qualified health centers, the Maine Hospital Association, Maine DHHS, and others are all working hard to assure adequate health care is available to all Mainers.

But I cannot emphasize how critical the social distancing is during the pandemic surge we are now experiencing. There are numerous social distancing mandates from all levels of government, including shelter in place orders. But they are only as effective as we the people are at implementing them.

Finally, I loved reading about how Mainers are putting their Christmas lights back up. Well, truth be told, I never got around to taking the window candles down. So, I’ll just leave them up…. and turn them back on. They are a needed reminder during these dark pandemic days of the lights we can shine on each other as we endure this challenging time, together.

Dr. Dora Anne Mills is the chief health improvement officer for MaineHealth and former head of the Maine Center for Disease Control and Prevention.

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