Coronavirus Outbreak in Oklahoma: The First 30 Days
Hale O’mana’o Research
We understand death for the first time when he puts his hand upon one whom
~Madame de Stael
We don’t know who patient zero was, and it is very unlikely that we will ever know.
Towards the end of December of 2019, in Wuhan, China, a city of nearly 19 million
people, 44 cases of pneumonia of unknown etiology were reported to the World Health
Organization. Eleven became severely ill. On January 7, 2020, the National Health
Commission China isolated a new coronavirus. Although the Chinese authorities initially
reported no known human to human transmission, by the end of January the new
coronavirus had spread to Japan, the Republic of Korea, and Thailand. On January 21,
2020, an individual who had traveled to Wuhan and returned to Washington on January
15 became ill. A clinical specimen was analyzed by the CDC and the diagnosis of a
travel-related coronavirus infection was confirmed. The first human to human
transmission in the US occurred on January 30, 2020 in Illinois.
On January 30, 2020, the WHO declared the coronavirus outbreak to be a Public Health
Emergency of International Concern (PHEIC). In the US, CDC Director Robert Redfield
stated, “Our assessment remains that the immediate risk to the American public is low.”
At that time, the US had only 7 reported cases.
By February 1, 2020, this novel coronavirus had spread to 23 countries outside of
China, for a total of 11,953 cases worldwide. By February 15, 218 cases outside of
China were identified. That would change rapidly. By March 1, 2020, there were
reported 7,169 cases and 98 deaths. 9 days later, Italy case count rose to 7,375 cases
with 366 deaths. The severity of this pandemic and its toll of the human population
would soon be made clear. My colleague from Italy explained their situation,
“Here the problem is mainly the lack of beds in ICUs, only 5200 scattered in all
the national territory. The CFR for COVID-19 has confirmed to be not high: in
Italy we have an extremely old population (+82-year-old) and this explains the
percentage points variation in deaths compared to China. Other factors for the
severity of the epidemic here, more than in China, are the high number of health
workers infected (here in my province, Sardinia, the 50% of infected are doctors
and nurses) and some irresponsible behaviors by someone that led to super-
The lessons we've learnt so far are:
1) that the containment should be aggressive and prompt, without "steps" and
hesitations, extraordinary challenge always need extraordinary measures, the
quarantine should be respected from the from the first till the last day;
2) the safety of the health workers is an absolute priority, this means to give the
right information on all the personal protection equipment’s and especially ffp3
masks to avoid the shortage of them as it is happened here in Italy;
3) it's important to grant a bed with artificial respiration to everyone who need it,
eventually creating new ones.
4) it's not a problem of China nor of Italy, of USA, or Iran or someone else, it's not
a virus of whites, yellows, blacks or greys, it's a problem of the world and only if
we'll be united against it we'll win this fight.
We should fight together as humanity, not alone, or even worst, against other
Please, be careful, that's not the final plague, but it kills.”
By March 7, there were 213 cases in the US and 11 deaths. One of those cases was in
Tulsa County, Oklahoma, a man in his 50s who returned from Italy on Feb. 23 and
began showing symptoms on Feb. 29. Three days later, another travel related case
from Italy was reported, again in Tulsa County.
On March 11, 2020, The WHO declared the coronavirus outbreak to be a pandemic.
Tedros stated”: “This is not just a public health crisis; it is a crisis that will touch every
sector — so every sector and every individual must be involved in the fight…we have
never before seen a pandemic that can be controlled.” He was right.
When the case count for Oklahoma was 7 on March 15, Governor Stitt posted that, “the
emergency declaration allows small businesses to get access to federal loans and lets
state agencies hire additional staff and make purchases quicker than they would
normally. The declaration also will allow Oklahoma hospitals to cut through red tape in
order to treat patients faster.”
March 16. The USA morning case count was ~2000 cases and 48 deaths. By the end of
day reporting, the total cases here in the US rose to a staggering 3503 and 58 deaths.
We're not doing fine Oklahoma. This is a critical junction. Pay attention.
The CDC has also recommended in general that gatherings of 50 or more people over
the next 8 weeks be cancelled or postponed. People taking everyday steps like limiting
large gatherings and frequently washing hands can substantially reduce risk around the
country. Healthy individuals can also make a difference by checking in older or
immunocompromised friends, family, and neighbors while maintaining physical social
On March 24, Gov. Kevin Stitt ordered that all non-essential businesses in the 19
counties that have confirmed cases to close for 21 days starting at 11:59 p.m.
Wednesday. The following day on March 25, the Oklahoma State Board of Education
voted Wednesday to close public schools statewide for the remainder of the school year
and to turn to distance learning which up to now, was prohibited in this state. On that
date there were 165 cases and 5 deaths reported with a doubling of cases every two
Governor Stitt also ordered elderly and vulnerable Oklahomans to stay indoors until
April 30, except for essential travel, such as to pick up groceries and prescriptions.
The next day, there were 248 cases and 7 deaths.
April 1 brought the case count in Oklahoma to 719 cases with 30 deaths. The projected
“peak” calculated to be on April 22. The majority of cases occurred in Oklahoma County
(Oklahoma City General area/192 cases/+37 in 24 hours), and Tulsa County (115 total
cases/+32 in 24 hours). We were just entering the exponential increase with limited
hospital bed and ICU beds. Our model of time-adjusted CFR remains the same at 9% in
symptomatic patients, mostly male and over the age of 50. Please be compliant with the
rules of quarantine. Younger age groups, as expected, are less compliant with this. We
will see a greater increase in both morbidity and mortality in the next six weeks due to
the limited healthcare capacity.
April 2. Today marks 3 weeks since the first case reported in Tulsa County on March
10, 2020. Since the lockdown two weeks ago, there has been some improvement in the
R (0) [based on 1-week incubation period]. The R (0) 1 week ago was 6.5; it is now 3.5,
within the range what we expect. We need this to drop to 1.0 (no transmission). If that
remains at that rate, we may see as many as 2500 total cases at day 28.
April 3. 988 cases/38 deaths; up 109 in 24 hours 40% of which are located in Oklahoma
and Tulsa counties. No real significant change in the time-adjusted CFR (9%) and R (0)
(3.1). It is likely we will surpass the predicted 46 deaths in three weeks. The good news
is that there are 13,000 testing kits. Most will be used for symptomatic patients. We all
need to do our part with avoiding transmission to get that R (0) down to 1.
April 5. 1252 cases and 46 deaths currently. The doubling every 2 days is better so
that's an improvement. Unfortunately, we hear stories of grocery stores being packed
and general complacency. We really need to maintain the distance and avoid any
unnecessary travel. Last week, both Oklahoma and Tulsa counties were in the top 10
nationally for people traveling outside their home. Just please limit contact with others
and be mindful of physical distance. For those of us that had been exposed and tested
positive, the OSMA recognizes the 3-7 back to work but they also recommended repeat
swabs to be sure you are negative. The median shedding time is around 10 days. If you
are still symptomatic, retest and wait 7 more days after revolution of symptoms so as to
not unintentionally transmit to someone else.
April 7. Today it is reported we now have 1327 cases and 51 deaths. The hardest hit
counties are Oklahoma (279/11), Tulsa (249/8), Cleveland (180/11), Creek (45/0),
Comanche (41/0), and Greer (26/3). Greer's situation is worth looking at as it's located
in rural SW Oklahoma and may predict serious consequences with its 12% non-
adjusted CFR. Rural Healthcare facilities are not likely capable of handling this.
Testing has also ramped up for the last two weeks. Hopefully this will continue.
The good news is that, despite the population mobility, the R (0) is 2.8 and no doubling
of cases from 4 days ago!
April 8. Our first reported case nearly one month ago was on March 7, 2020. On April
12, 2020 the OSDH has reported 1970 cases with 96 deaths (non-adjusted CFR 4.92%,
time-adjusted CFR 7%.
How are we doing in this State when compared to other nations when they reported
Not well. As of today, 53 countries have reported ~2000 cases (plus/minus ~500) and
were the basis of this report. The mean # cases was 2010.8 (standard deviation 168.7)
and a mean #deaths to be 44.3 (standard deviation 42.8) resulting in an overall CFR of
2.2%. 14 countries reported a CFR of <1% (green) and 2 were >6% (red).
April 12. Day 31
How are we doing in this State when compared to other nations when they reported
Not well. As of the date of this analysis, 28 states have reported ~2000 cases
(plus/minus ~200) and were the basis of this report. The mean # cases was 2073.1
(standard deviation 128.3) and a mean number of deaths 45.8 (standard deviation 24.3)
resulting in an overall CFR of 2.2%. Only the States of Washington (5.2%) and
Kentucky (5.1%) reported a higher case fatality rate at this point compared to Oklahoma
at 4.9%. When we perform a time-adjusted case fatality rate (TACFR) taking into
consideration when that individual death was first reported as a confirmed case, that
TACFR has hovered between 6-10%. Furthermore, as of this report, there have been
457 hospitalizations and 99 deaths. Assuming all 99 deaths were also recorded as
hospitalizations, that would result in a frightening 20% risk of death if the illness is
severe enough to require hospitalization. We won’t have the ICU capacity to address
these intensive care admissions at the current rate.
We are at a critical point in this outbreak here in Oklahoma. Do we start opening up
nonessential businesses in two weeks? Personally, that might be premature since it is
unlikely our peak will be reached on the projected date. Retuning to work given the
current CDC recommendations of 7 days after onset of symptoms and three days after
resolution of symptoms may not be sufficient. Why? The median time to minimal virus
titers is thought to be around 8 days. RT-PCR analysis of SARS-CoV-2 RNA and
antigen is detectable up to 7 days before symptoms begin and may persist up to 28
days (37 days in another report). The duration of symptoms lasts around 14 days. The
IgG antibody response is just beginning its rise for protective immunity. If we push to
eliminate transmission and get the reproductive number down to R (0) =1. That would
require that 21 days should pass before a confident release from quarantine since onset
of symptoms to reduce the risk of transmission to less than 90%.
We agree with the following statement from Rapid Expert Consultation on SARS-CoV-2
Viral Shedding and Antibody Response for the COVID-19 Pandemic (April 8, 2020).
Waiting for all tests to be repeatedly negative is the most conservative approach but
may result in prolonged unnecessary isolation. Assessment of humoral and cellular
immune response may also be informative.
Gaps in knowledge:
Duration of shedding of infectious virus by recovered patients and the
relationship to detection of viral RNA
Knowledge of immune mechanisms responsible for virus clearance that might
predict recovery and help determine when patients are no longer infectious
Immune correlates of protection
Duration of protective immunity
We would add the following additional recommendations:
Reassess current interventions as to efficacy and incidence of adverse reactions
Promote research into effective vaccine development
Increased utilization of effective proven treatment options by clinical trial
Recognize the “second wave” of transmission (resurgence) and reassess the
impact of early intervention (steroids, others) on the incidence of recurrence of
COVID-19 in recovered patients
Identification of new zoonotic and ecologic niches of SARS CoV-2 to reduce risk
Two negative repeat RT-PCR tests or 21 days following onset of symptoms or 1
week after complete solution of symptoms before release from quarantine so that
we reduce the risk of transmission to <10%.
Our physicians and all healthcare providers and staff cannot be overwhelmed at this
point. We have a duty to our families, friends, and neighbors if we are to recover in a
Data obtained from the following resources:
1. WHO SARS CoV-2 situation reports
2. Johns Hopkins Coronavirus Resource Center
3. Coronavirus COVID-19 Data in the US repository
4. Oklahoma State Department of Health [https://coronavirus.health.ok.gov/]
5. Rapid Expert Consultation on SARS-CoV-2 Viral Shedding and Antibody
Response for the COVID-19 Pandemic (April 8, 2020)
6. GUIDANCE ON THE ESSENTIAL CRITICAL INFRASTRUCTURE
7. IHME COVID-19 Projections [https://covid19.healthdata.org/united-states-of-
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