Mini-Throughput: COVID-19

Scanning electron microscope image of SARS-CoV-2 (yellow). Credit: By NIAID Rocky Mountain Laboratories (RML), U.S. NIH

Before we get into this…my training is in astrophysics. I’m not a virologist, a biologist, a doctor or an epidemiologist. My goal here is not to come at this from a point of expertise; it is to distill what I’m reading, learning and understanding about an ongoing science news story. So I welcome comments, criticisms and clarifications from people who know more about this than I do.

The news lately has been filled with stories about the Wuhan Coronavirus, also known as COVID-19. The disease first appeared in Wuhan, China, having apparently jumped species, most likely from bats. It has now spread to all parts of China and forty countries, including the United States. 80,000 people have been diagnosed with the disease and 2700 have died of it. Initial response was slow but is now including efforts at quarantine and curfew. You can check the spread of the disease at Johns Hopkins online map. Last night, the President had a press conference addressing the growing concern.

So how worried should we be about this?

First of all, coronaviruses are not new. These are common and you have had many coronavirus infections in your lifetime, mostly as the common cold. Sometimes a strain comes along that can cause much more severe illness, including death. SARS and MERS were coronaviruses.

What makes the COVID-19 virus so concerning is that earlier deadly coronaviruses made their hosts sick severely and immediately. They would seek treatment quickly, which made the disease easier to contain. This one, for the vast majority of people who catch it, is mild or even asymptomatic. But it is still quite infectious (the last estimate I saw of the R ratio — the number of people an infected person could be expected to pass it onto — was 4, which is high). So the concern is that the vast majority of people won’t know they have the disease.

James Hamblin’s excellent, if unnerving, piece in the Atlantic argues that these factors make it unlikely we are going to contain the disease.

[Harvard professor Marc] Lipsitch predicts that within the coming year, some 40 to 70 percent of people around the world will be infected with the virus that causes COVID-19. But, he clarifies emphatically, this does not mean that all will have severe illnesses. “It’s likely that many will have mild disease, or may be asymptomatic,” he said. As with influenza, which is often life-threatening to people with chronic health conditions and of older age, most cases pass without medical care. (Overall, about 14 percent of people with influenza have no symptoms.)

Lipsitch is far from alone in his belief that this virus will continue to spread widely. The emerging consensus among epidemiologists is that the most likely outcome of this outbreak is a new seasonal disease—a fifth “endemic” coronavirus. With the other four, people are not known to develop long-lasting immunity. If this one follows suit, and if the disease continues to be as severe as it is now, “cold and flu season” could become “cold and flu and COVID-19 season.”

The initial study out of Wuhan gave a fatality rate of 2% based on 72 thousand cases. For comparison, a typical flu has a fatality rate of 0.1%. Now it’s hard to know exactly how accurate that is since it’s turning out that most cases are mild or even asymptomatic. Another study claims the fatality rate may be as low as 0.8% once you account for that, possibly lower. But let’s take the 2% figure. If you break it down, you can start to see the outlines of the scenario that has people scared. For people under 50, the fatality rate is 0.4%. For those over 80, it’s 15%. And it appears that those with underlying health problems — heart conditions, diabetes, etc. — are the most vulnerable. Put it all together and you have a scenario where the majority of the population unknowingly spreads a disease that is lethal to a minority.

If you’re young and healthy, the odds are that you’ll get no symptoms or serious but not fatal ones. But for those in our communities who are at risk — our grandparents, diabetics, those with hypertension — the odds are not good. If you’re young and healthy, you should be thinking less about the risk to you and more about the risk to others.

The initial government responses were slow but are picking up speed. Right now, they are mostly focused on trying to contain the virus, through quarantines and curfews and self-isolation of international travelers. They are also encouraging better hygiene (a new study indicated that routine hand-washing in airports could cut the spread by 30-70%). The problem is that, for the reasons I outlined above, this may not work. We could have hundreds of people in the country right now who have COVID-19 and don’t know it. And that means that in weeks we could have thousands and in months, we could have millions. Maybe that scenario won’t happen; maybe we’re catching everyone who comes into this country. But it behooves us to treat is as a very real possibility and have a fallback position if the disease becomes not only widespread but a regular event.

Fortunately, we already have a lot of the pieces in place to deal with that eventuality. A former director of the CDC has written about resources we have in place, waiting like pre-positioned military equipment to defend against an enemy. I’ve elided the details to focus on the bullet points.

Based on extensive planning for an influenza pandemic by many national and international experts, we must do eight things — some immediately and some in the coming months — as we shift from the initiation phase of the pandemic to the acceleration stage:

1. Find out more about how Covid-19 spreads, how deadly it is and what we can do to reduce its harms

2. Reduce the number of people who get infected.

3. Protect health care workers

4. Improve medical care and prevention of Covid-19.

5. Protect health services

6. Support social needs

7. Protect economic stability

8. Invest in public health

The President and Congress are also moving to pour money into pharmaceutical companies that are researching treatments and possible vaccines (one of which may already be ready for testing). The news on the biotech front is both good and bad. Good, in that we’ve studied coronaviruses for some time, so we’re not starting from scratch. Bad in that these treatments will not be available quickly. We’re probably looking at a year or more (which itself is an unbelievable near-miraculous timescale).

We also need to be thinking long-term. COVID-19 is not the first potential threat of a pandemic and it won’t be the last. Whatever lessons we learn from this need to be applied to future pandemics (Lesson One: the President needs to stop gutting the programs we have to respond to events like this). This is going to test us. And we need to learn from that test, not throw around blame.

So the danger of COVID-19 is quite real. This isn’t just media hype. There is a possibility that we won’t be able to contain this and that many people will die. We need to be realistic about that dire possibility.

But we also need to not panic. We are not helpless and we are not going to just let this happen. We are bringing immense resources to bear. And, in only two months, we have already made amazing progress in learning about this disease and looking for ways to address it. This despite an attempt by the government of China to pretend it wasn’t happening at all.

There’s more good news. You are not helpless. There are things we citizens can do to fight the spread of COVID-19. Probably the most important: washing our hands:

Here is the best advice I can give you, to avoid any virus and flu: Be intentionally hygienic in public and during interactions with others. Hand hygiene is a cornerstone of infection prevention. Effective hand hygiene requires appropriate duration and thoroughness, which should be a goal each time our hands are cleaned.

Use soap and water for the amount of time it takes to sing the “Happy Birthday” song, or an alcohol-based hand sanitizer. In a study we conducted on hand hygiene, the most common areas missed by hand washers were thumbs, wrists, and in between fingers.

Surgical masks are a mixed bag. The research I’ve found shows they don’t do a lot to keep someone from catching a disease. But they can do some good in preventing a person from spreading the disease by containing the particles in their sneezes and coughs.

The CDC has told people to prepare for possible lifestyle disruptions. Some people have interpreted this to mean stocking up on food and water — prepping. But the likelihood that you will have to barricade your home and survive on MRE’s is extremely low. The worst-case scenario is similar to what is going on in China right now — curfews, school closures and working from home. The more likely is some curtailments — cancelled conferences, telecommuting and social distancing (not touching people unless you have to). And it may not even come to that.

Another thing people can do: get their flu shots. Diagnosing a patient with COVID-19 — or anything else for that matter — gets lot easier if you know they are unlikely to have the much more common flu. A few years ago, I wrote about this in the context of my son’s bout with pneumonia:

My father, the surgeon, likes to say that medicine is as much art as science. You can know the textbooks by heart. But the early symptoms of serious diseases and not-so-serious one are often similar. An inflamed appendix can look like benign belly pain. Pneumonia can look like a cold. “Flu-like symptoms” can be the early phase of anything from a bad cold to ebola. But they mostly get it right because experience with sick people has honed their instincts. They might not be able to tell you why they know it’s not just a cold, but they can tell you (with Ben, the doctor’s instinct told him it wasn’t croup and he ordered a chest X-ray that spotted the pneumonia).

Most doctors today have never seen measles. Or mumps. Or rubella. Or polio. Or anything else we routinely vaccinate for. Thus, they haven’t built up the experience to recognize these conditions. Orac, the writer of the Respectful Insolence blog, told me of a sick child who had Hib. It was only recognized because an older doctor had seen it before.

When I told the doctors Ben had been vaccinated, their faces filled with relief. Because it meant that they didn’t have to think about a vast and unfamiliar terrain of diseases that are mostly eradicated. It wasn’t impossible that he would have a disease he was vaccinated against — vaccines aren’t 100%. But it was far less likely. They could narrow their focus on a much smaller array of possibilities.

Medicine is difficult. The human body doesn’t work like it does in a textbook. You don’t punch symptoms into a computer and come up with a diagnosis. Doctors and nurses are often struggling to figure out what’s wrong with a patient let alone how to treat it. Don’t cloud the waters even further by making them have to worry about diseases they’ve never seen before.

If you come into an ER with flu-like symptoms, they’re going to think you have the flu. If you come in with flu-like symptoms having gotten a flu shot, then they’ll think about COVID-19. You should get the flu shot anyway. If nothing else, it will reduce the burden on a healthcare system that may be about to get slammed. But you should especially get it now when doctors are dealing with an unknown.

In the end, COVID-19 is a very serious concern. It is infectious, it is spread easily by asymptomatic carriers and it can kill. It may very well spread far and wide enough that it’s something we have to deal with on a regular basis. But it is unlikely to be the end the world. We have been through worse. The 1918 Spanish Flu — an H1N1 variant — infected a quarter of the world’s population and killed 10-20% of those who caught it. Before the advent of vaccines, people — especially children — were regularly killed or maimed by smallpox, measles, mumps, rubella, polio and a host of other diseases. In some parts of the world, they still are. Talk to some of your seniors and they’ll recall outbreaks of these diseases and the terror that would descend on communities when it happened. We soldiered on.

And we are not taking this lying down. There are things we can do on a personal level to slow the spread. There are things being done on a national and international level to slow the spread. We are fortunate right now to live in an era of relative peace and reasonable international cooperation. And we are very fortunate to also live in a golden age of science. Some of the finest minds in human history are using the most sophisticated technology in human history to figure out ways to treat or vaccinate against this virus.

Coronavirus may blow over. Or it may kill millions. The most likely scenario is somewhere in between — like a bad flu season. But no matter how this goes, we are fighting this and we are fighting it hard.