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Coronavirus—Lessons From Evolving Information

posted in Asthma, Clinical Science Research, Infectious Diseases

Unless someone has lived under the proverbial rock in the past month and does not obtain current event information, or is not even seeing the financial markets’ numbers from this past week,  we are all aware in the USA of the novel coronavirus (named on February 11th as COVID-19) outbreak that began in China about 2 months ago. We are relying on headlines and understandably changing scientific information to judge how we should respond by action and emotion.  Some clarifying and personal thoughts from what we know to-date:

Mortality:
We are accustomed to hearing about some deaths, especially in the elderly population, from influenza—the virus against which we get vaccinated every fall. Since 2010, the CDC (Center for Disease Control) estimates that there have been between 9 million and 45 million influenza illnesses per year.1 The CDC further estimates that there are between 12,000 and 61,000 deaths from influenza per year.1 The mortality rate derived from these numbers during these years can range from 0.1% to 0.9%.

Based on statistical data from countries with varying degrees of confidence in their reliability, the mortality rate from the COVID-19 virus is NOT that of Ebola virus, which has been approximately 60%.  It is also NOT that of the two prior coronavirus epidemics since 2000—SARS in 2002-2003 and MERS in 2012.  The mortality rate of MERS has been 34%; the mortality rate of SARS has been 9.5%.2

In countries with deaths and more than 3 confirmed cases, the mortality rate from COVID-19 is the following as of 10AM Central European Time on February 29th:

China:  2,838 deaths/79,394 confirmed cases (3.6%)3

Outside of China:      86 deaths/6,009 cases (1.4%)3

     –International conveyance (Diamond Princess ship): 6 deaths/705 cases  (0.85%)3

     –South Korea:                                                           17 deaths/3,150 cases (0.5%)3

     –Italy:                                                                         21 deaths/888 cases    (2.4%)3

     –Japan:                                                                        5 deaths/230 cases     (2.2%)3

     –Iran:                                                                         34 deaths/388 cases   (8.8%)3

     –France:                                                                       2 deaths/38 cases      (3.5%)3

     -United States of America:                                      death/62 cases     (1.6%)3                               

As we interpret this data, we need to keep in mind a few things.  Mortality rates can vary with respect to the quality of the general and local health care services available in that country.  The deaths tend to be in older individuals.  We also don’t know how quickly those who were infected sought medical care.

Detection:
If you have fever and cough, these may be caused by viruses that are much more common than COVID-19.  Rhinoviruses, influenza viruses, parainfluenza viruses, RSV and four other coronavirus species also cause common cold symptoms.  For the record, these four other coronaviruses are named 229E, OC43, NL63 and HKU1. Shortness of breath or wheezing do increase the concern to test for COVID-19.

Ordering a test for COVID-19, though, will depend on either:

(a) recent travel (at this time) to China, South Korea, Italy, Japan, Iran and Hong Kong; or

(b) close contact with a person confirmed to be infected with COVID-19.

This test is only available at the Illinois Department of Public Health with approval from local public health departments.  When I read about confirmed cases in the USA and in other countries, I am assuming these cases are based upon detecting viral RNA that has greater than 85% identity with a coronavirus that infects bats (the likely animal source of COVID-19) and not with coronaviruses 229E, OC43, NL63 and HKU1.  The news media could be more helpful by explaining better what a confirmatory test means, and how specific it is for COVID-19.

Supplies:
As I wrote five months ago, most of our prescription medications are manufactured in China and India.  The likely disruptions in production within China and in transportation of products from China should signal to us that when we go for refills of our medications within the next month, we need to prepare for being told there will be delays or unavailability.   We may want to consider now to temporarily decrease taking our prescription medications to every other day—IF MEDICALLY REASONABLE AND TOLERATED—until the supply chain is restored.

Protection:
On February 12th, I listened to a webinar from the American College of Allergy, Asthma and Immunology about COVID-19.  The infectious disease specialist from the University of North Carolina reminded us that MOST CASES ARE MILD. He recommended the following steps to be aware of to avoid becoming infected:

  • Try to stay 6 feet away from a person with respiratory symptoms of coughing and sneezing.
  • It’s unknown if the virus can be transmitted from touching objects. In general, coronaviruses survive poorly on objects.  But, there’s nothing wrong with adjusting our daily movements—such as by touching elevator buttons with our knuckles instead of with our fingers, or by avoiding handshakes.
  • Clean hands with soap and water or with an alcohol-based hand rub.
  • Thoroughly cook meat and eggs—as the first case of COVID-19 in the United States was associated with gastrointestinal symptoms.
  • Avoid unprotected contact with live wild or farm animals.

Clinicians would– –as all of us would– –want some certainty to diagnose and treat patients based on well-established information instead of on a moving target of findings.  Based on what we know about COVID-19, the virus is more contagious but less lethal than MERS and SARS.  Those with chronic lung or heart conditions or with diabetes need to be attuned to their health and have a lower threshold for seeking medical attention.  So do those who are either immunocompromised or immunosuppressed from certain other diseases or from certain drugs. If the combination of fever surveillance, isolation of infected patients and quarantine of their contacts limited the spread of SARS, then those steps are prudent to use to contain COVID-19.

Being isolated or quarantined is not pleasant.  I didn’t enjoy it for two weeks in 1986 when I contracted chicken pox during third-year medical school and had to rely on food left for me at the doorstep of my home.  I saw last November the isolation wards of the hospital building on Ellis Island where immigrants with tuberculosis and yellow fever were isolated for weeks and months in large rooms without privacy and the modern amenities that we take for granted.  Loss of physical freedom and limited ability to socialize during this time are emotionally very difficult.

However……we do what the best science, when it is sensible and derived rigorously, recommends for us.  Remembering Franklin Roosevelt’s famous words that “the only thing we have to fear is fear itself,” we should proceed during this period of uncertainty in the British tradition: “Keep calm and carry on.”

Dr. Klein

1https://www.cdc.gov/flu/about/burden/index.html
2New England Journal of Medicine 382;8:692-694.  February 20, 2020
3https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdf?sfvrsn=7203e653_2