COVID spike in Black Hills coming: Q&A with Dr. Shankar Kurra about the future of COVID locally

EDITOR'S NOTE: This story is from interviews were conducted and finalized July 28.

RAPID CITY — As the nation reacted to the COVID-19 pandemic in March with economic shut downs and mass quarantines in hot spots, some small towns in South Dakota limited business and restricting gatherings. These actions seemed to do the trick, and our state has enjoyed relative low infection numbers and death rates. But as people in states hardest hit by the virus seek an escape from the crowded streets of bigger cities, cabin fever stricken citizens travel to states with more wide-open spaces such as South Dakota.

The Pioneer spent some socially distanced time with Dr. Shankar Kurra, vice president of medical affairs for Monument Health to ask what medical experts are preparing for this year’s tourist season may bring.

Q. “We’ve kind of come a long ways since we first heard the words ‘COVID-19.’” What have we learned so far? Where are we now compared to where we were back in March and April?”

A. “Yeah, so what is pretty obvious as you can see from all the data on the number of cases that the first wave is still on. The Northeast portion of the country has gone through a pretty good exposure. It varies if you look at the Sero-prevalence studies that have been published, anywhere between 10% to 20% might be exposed and now we’re seeing the same phenomenon in the South and the West. And as you know the Northeast is only made up of about 50 million people and the Southwest combined account for 200 million people so that’s a lot of people and a lot of tests and a lot of positives.”

Kurra said this region is seeing increased spread of the virus in people of all ages, who are no longer being told to stay home, and don’t feel the need to limit travel.

Kurra explained that there is a lag between the time a positive case is confirmed, hospitalization takes place, and death occurs, which accounts for why it could take upwards to a month before some public health reports show a true picture of what is taking place within a population.

As more and more people travel from other parts of the country to area with lower cases, such as South Dakota, Kurra said the virus will have the same impact on our region as it has in areas hit in it’s early days.

“The disease itself has not changed, the case fatality ratio is the same, the spread is the same, the percentage is the same – what we are seeing differently is just that there’s whole areas of population that are naïve to this so when all is said and done, just like in New York and New Jersey in the early stage, we’ll end up seeing a similar situation.”

Q. “So what we’re seeing is not necessarily a change in the virus itself, but it’s a change in the way people are reacting to it?”

A. “Yes, and actually not (how) people are reacting, but the people’s behaviors. The spread of most respiratory viruses; the first SARS, the second MERS, this one, and all the influenza viruses depend on human-to-human contact (to) spread. Contact and droplets, that’s why we say, ‘wear a mask, six-foot distance, wash your hands, don’t touch your face.’ Airborn spread is extremely rare. Not only is it rare, it (needs) very specific settings, otherwise airborn spread is almost unheard of. So what we are basically seeing is behavior changes, which are (helping the) spread, and the virus depends on that behavior of contact and droplet spread. So if you have large groups of young folks going to little spaces like bars, (and restaurants), … that’s where the spread is occurring. At least that’s our best information that we have. So it’s not (the) reaction of the human body to the virus, but it’s our behaviors.”

Q. “Many of the business restrictions issued by South Dakota towns were lifted in May. When do you think we will see the results of that decision?”

A. “So clearly that leads us to what’s happening in the South and the West (where) all the various degrees of openings has actually led to a massive spike in cases. That’s the difference for us, and I would say this of most of our states in the Midwest, we will always be the last ones (affected).

Kurra said historically, states in the Midwest have seen spikes in nation-wide cases later than coastal states.

 “As we all know, our reopening is slightly different than other (states’) reopenings. We will see a large influx of people from other areas coming in, and unfortunately we won’t know all of the numbers of those that come and go but those that are here are going to be at risk as a result of that large influx. That reopening is going to play out slightly later, but almost identical to the South and the West as we’re seeing the cases. So reopening, the full story won’t be told at least for the Midwest, probably until September.”

Q. “Why is it that Midwestern states have sort of a lag from the coastal states?”

A. “I think that there’s several factors. We are remote, number one. You don’t have a hub like say, Denver, or Louisiana does, or New York or New Jersey, there are actual hubs where people travel to then reroute again.

Kurra referenced a peer-reviewed paper published by medRxiv titled

“Estimating the establishment of local transmission and the cryptic phase of the COVID-19 pandemic in the USA.”

(The paper) showed us that the initial spread occurred through those hubs from travel from Europe mainly but then all subsequent spread through all of those places that are not hubs occurred by domestic, internal travel, basically by road.

Kurra explained that because there are no large airports or travel hubs in South Dakota, it has taken longer for the virus to reach us in significant numbers.

“We’re almost like the Australian Outback, you’re so far away that it’s hard to get to. That kind of naturally lends itself to a slow spread.

(The paper) also shows that the subsequent spread tremendously outnumbered the airline spread. That’s why the Northeast was affected immediately … they have giant hubs, and then you get the (massive outbreaks in the) South and West now because we opened up those states and people are travelling freely and doing everything to spread it. Not on purpose obviously, that’s just what I meant by our behavior (has changed). That’s also not a moral statement. It’s more a reflection, or a direct commentary on what’s occurring.

“Homes are far apart. Social contact for a rancher is different that social contact for a city person.”

He also said the rate of the spread is slower in this region due to lower population density.

Q. “So with all the major events that are bringing large crowds to the state, coupled with an already robust tourist industry, we can expect to see South Dakota’s peak infection period later than previously predicted?”

A. “Correct. For a region like us, I can say that just based on the testing done for folks that come here, they’re from all over, they’re from the West Coast, Northwest coast, South, far flung as far as Florida, we get people from everywhere, so the local spread will not occur until you have really large crowds here because the locals themselves are a lot more careful I would say.”

Q. “So the facts of our sparse population, and remote proximity to the coastal states means that South Dakota was never going to see a large spike in COVID cases until we started seeing that influx in visitors from other states and now we’re going to start to see our spike manifest?”

A. “Yeah, we hope not, but we know the fundamentals of (the) epidemiology of the disease are very straight forward.”

Kurra compared the spread of COVID-19 to the way influenza is spread, although he cautioned not to take the analogy too far.

“If you have large gatherings, people close to each other, you can’t avoid contact, you can’t avoid droplets, and that’s what leads to the mass spread. It’s like kids going to school and catching the winter bug, every winter we see it. We call it flu season, and there’s a reason why.”

That said, Monument Health officials have previously told the Pioneer that people who have the common flu transmit it on average to 1.5 people. With COVID-19, that rate of spread climbs to 2.5 to 3 people infected.

Q. “Given that we’re in sort of an ideal situation in this part of the country because we’ve been able to see how the more-densely populations have reacted to this, what can we be doing to prepare for when that spike occurs in September?”

A. “Great question, that is probably the one question I love answering every time it’s asked. I think the number one thing is do the right thing to prevent spread, which means wear a mask, wash your hands, avoid contact, and keep that six foot distance, do not touch your face unless you wash your hands, and try to avoid crowds. If you’re going to go into those crowded situations make sure you wear a mask. That could, to a large extent minimize it.”

Kurra said that Japan has been able to avoid some of the harsh economic shutdowns and lockdowns seen by many major cities throughout the U.S. by issuing a public health message of avoiding the “Three C’s,” closed spaces, crowded places, and close-contact settings.

“As you well know Japan is a highly-densely populated island nation, and their biggest population centers haven’t seen the numbers we have seen. That’s our only chance to keep the numbers down and keep the health system from being overwhelmed.”

Q. “So it was almost like we adapted our behavior to the virus prematurely to when we would actually be affected by it out here? Now is when we need to be taking those measure we adopted back in March and April.”

A. “Perfectly said. I like the word prematurely, but in this case there is the prejudice that the word brings doesn’t apply. I think in this case that you couldn’t be premature at all because who knows what would have occurred. But I think you’re right, what we’ve done is a nice dry-run up to this point. These are the things that will save us and we are the only ones that can save us.”

Q. “The efficacy of wearing a mask has been thrown into question by some high-level officials. What is it about wearing a mask that is so affective? Is a certain type of mask more effective than others?”

A. “I think what this whole mask thing people misunderstand is, you do not want N95 or any kind of technical mask. All you want is a simple cloth mask. The difference here is (that in a hospital setting) you know which person is in very close proximity of an actual well-identified case. What we’re doing in the public is we don’t know who has it and who doesn’t, and not only that, we know that the day before people present the symptoms, they have enough (of the virus) that they can infect someone. And that’s what the mask is (for). It’s to prevent you, who could tomorrow be developing a fever, from spreading it inadvertently to someone. And the mask (helps) stops that. The mask by itself is not going to help you, you still have to wash your hands (maintain) the six-foot distance, stop going to crowded spaces. What (wearing a mask has) clearly been shown to do in addition to all of these, the mask prevents that chain of human-to-human spread very efficiently and very effectively.”

Q. “Is there any reason somebody shouldn’t wear a mask?”

A. “There are none. All the urban legends and myths around mask wearing and affecting your breathing and all that is not true. Obviously you want to wear this mask when you are in close proximity or going out to closed spaces, what you’re doing is protecting others. There’s really no time or place where a mask is a no-no, but of course, you’re only protecting others so if you’re not going to be around people you’re ok without a mask.”

Kurra urged readers not to get caught up in the politicized debate that has permeated the best practice policies of combating the spread of COVID-19.

“The important thing is, let’s not debate on what we should or shouldn’t do,” Kurra said. “The epidemiologists (and) our own data based on the climbing infection rates here are very clear. Wear a mask, keep your six-foot distance, wash your hands, don’t touch your face, and avoid crowds.”

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