COVID-19 : WE not ME
A look at the facts behind COVID-19 and why they matter
Introduction and Summary
I earned my Master’s in Public Health, with concentrations in Policy and Epidemiology, approximately 15 years ago from the University of Illinois School of Public Health. In mid to late February I noticed incomplete or incorrect information about COVID-19 circulating online and thought it was worth trying to break down COVID-19 in a fact based way.
In public health pandemics information, communication, and preparation are useful tools in mitigating community health risks.
In this piece I will try to address two main questions:
What is COVID-19?
Why should we care?
Before I get into this breakdown let me give you the headline takeaway. So what’s the 2 second elevator speech conclusion on COVID-19?
COVID-19 is a “WE” problem, not necessarily a “ME” problem.
If you are a relatively young relatively healthy individual who has no serious pre-existing condition and are not immunocompromised, COVID-19 does not, in all likelihood, present a significant or dangerous health risk to you personally (though it may still diminish your respiratory health for the future).
HOWEVER, (and this is a big however) the purpose of global quarantines and travel restrictions, as well as other “seemingly excessive” precautions, is because COVID-19 does present a very serious health risk for those that are elderly and/or have pre-existing conditions and/or are immunocompromised.
So these public health prevention measures may not be about protecting you as much as they are about protecting your parents, grandparents, and other at-risk loved ones.
The SARS-CoV-2 virus, which causes COVID-19:
can spread asymptomatically
appears to be an airborne virus
can survive on inanimate objects and surfaces for hours if not days. It may even live on your phone for up to 96 hours. This belief is based on the fact that, according to the WHO, SARS can live on glass surfaces for up to 4 days.
can spread essentially undetectably for up to 2 weeks before someone knows they're an infected carrier
is subject to community spread where the sources of infections can no longer be traced
has a case mortality rate for the elderly that is 4 times as high as for the population at large
has no known vaccines or proven therapeutics though clinical trials are underway for both
The Life Care Center nursing home in Kirkland, Washington is emblematic of the very worst that COVID-19 can become where an as yet unknown number of patients have been infected (63 residents have been transferred to local hospitals with 49 residents remaining in the facility). 21 of the remaining 49 residents have tested positive for COVID-19.
To date at least 13 residents have passed from the virus with 19 total deaths linked to the facility. Roughly 70 staff members have begun to show signs of symptoms as well. This is a nightmare scenario that, God forbid, may face other nursing homes and healthcare settings as the disease progresses.
So while COVID-19 may not touch you personally, or your children (whether you are infected or not) it is likely to cause real damage to the elderly and at risk population in this country, not to mention the healthcare workers.
What’s the bottom line here? If you care about the health and well being of your parents, grandparents, and/or of your friends’ parents and grandparents, you should really take COVID-19 seriously.
Additionally, because of elevated and continuous exposure, our nation's healthcare providers are also at risk of being infected - this could place a serious stress test on our healthcare system for patients battling all illnesses, not just COVID-19.
Scott Gottlieb, Trump's former FDA commissioner, predicted the coming weeks will "change the complexion in this country," adding that lockdowns of certain states or cities "are going to need to happen" or health systems will get exhausted and fatalities will rise quickly.
Let’s break this all down by the facts and numbers below:
What are coronaviruses?
Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV).
What is a novel coranavirus?
A "novel" coronavirus (nCoV) is a new strain that has not been previously identified in humans.
What is COVID-19?
COVID-19 is short for “Coronavirus Disease 2019.” COVID-19 is the name of the disease caused by the current coronavirus known as SARS-CoV-2. So COVID-19 is the name of the disease and SARS-CoV-2 is the name of the underlying virus. SARS is short for Severe Acute Respiratory Syndrome.
What is Nsp15?
Scientists in Chicago recently created a 3D mapping of the protein structure of the COVID-19 SARS-CoV-2 virus, which allows scientists to figure out how to interfere in the pathogen’s replication in human cells. In that mapping they discovered Nsp15.
“The newly mapped protein, called Nsp15, is conserved among coronaviruses and is essential in their lifecycle and virulence,” said Joachimiak. “Initially, Nsp15 was thought to directly participate in viral replication, but more recently, it was proposed to help the virus replicate possibly by interfering with the host’s immune response."
It is believed that the continued analysis of the virus and its core proteins will lead to more targeted and effective therapeutics and vaccines.
Are there multiple strains?
Yes. Scientists with Peking University’s School of Life Sciences and the Institut Pasteur of Shanghai in a preliminary study found that one strain — type “L” — of the virus was more aggressive and accounted for about 70 percent of the strains analyzed. The second — type “S” — was less aggressive and accounted for about 30 percent of analyzed strains.
It is possible for more strains and mutations to occur, which makes understanding COVID-19 more of a moving target.
Is COVID-19 like the flu?
COVID-19 is not the flu – they are caused by different viruses, they require different treatments, they transmit differently, they have different incubation periods.
Again, COVID-19 is NOT the flu.
They both present with similar symptoms:
Both cause fever, cough, body aches, fatigue; sometimes vomiting and diarrhea.
Can be mild or severe, even fatal in rare cases.
Can result in pneumonia.
Both can be spread from person to person through droplets in the air from an infected person coughing, sneezing or talking.
COVID-19 is caused by a new novel coronavirus named SARS-CoV-2.
The flu is caused by influenza viruses.
COVID-19 appears to be transmitted also through the airborne route (though it is unconfirmed) - meaning that tiny droplets remaining in the air could cause disease in others even after the ill person is no longer near. For this reason the CDC recommends health professionals adhere to CDC airborne protocols.
The flu does not.
Antivirals and home therapeutics exist to treat or mitigate the flu. For example, you can get a Tamiflu prescription to take at home. The flu also has vaccines available (flu shots).
There are no current known therapeutics or vaccines for COVID-19. Remdesivir from Gilead appears promising. Takeda Pharmaceuticals is also working on hyperimmune globulin treatments that may also have some promise as an in-hospital therapeutic. Vaccines will not be available till sometime in 2021, but multiple labs are preparing their vaccines for clinical trials as early as April.
A few things to keep in mind when contrasting the flu vs COVID-19.
According to the WHO COVID-19 is presently 3 times as deadly as the flu: “Globally, about 3.4% of reported COVID-19 cases have died. By comparison, seasonal flu generally kills far fewer than 1% of those infected.”
Domestically, COVID-19 can be between 10 and 30 times as lethal as the death rate of the flu. In the US the flu mortality rate is around 0.1% according to the New York Times and Dr. Anthony Fauci.
COVID-19 cases can present as asymptomatic for up to 14 days, so it is harder to know who is carrying / spreading the disease because they are not presenting with symptoms as fast as with the flu.
On average someone with the flu will give the flu to 1.3 more people (the R0 value) - with Coronavirus that value is 2-3 times higher but we have seen instances where an individual can directly lead to more than 10 cases and indirectly lead to a mass breakout. For example despite China and Italy's quarantines, epidemiologists have traced cluster outbreaks in both countries to travel between the two nations. The Brazil cases have been linked to travel from Italy, and so on and so forth.
The positive aspect of COVID-19 is that if you are a relatively young, relatively healthy individual your health is not at serious risk of being seriously harmed by contracting COVID-19.
According to the World Health Organization, as of February 20, 2020, 78% of COVID-19 cases are found in the 30-69 age group. According to China’s CDC as of February 11, 2020 87% of the cases in China are found in the 30-79 age group. Approximately only 2% of cases were found in those age 19 and under, with less than 1% of cases found in those age 9 and under. Similarly, fatality rates, according to China’s CDC appear to be 0.2% in those aged 10-39.
According to the World Health Organization the overall mortality rate of COVID-19 is under 3.5% and more than half of those that have contracted COVID-19 thus far have recovered.
The bad news is that COVID-19:
cannot be contained despite global lockdowns
has no known vaccines (trials are underway)
has no proven therapeutics (trials are underway)
may reappear in the second half of the year as a seasonally recurring disease
Despite the virtual lockdown of 150 million people in China, the virus has spread around the world in a matter of months, including Italy, and South Korea which also have enacted their own broad lockdowns. Italy has now expanded its emergency measures nationwide.
These lockdowns are unable to prevent the spread of the virus as epidemiologists have traced the virus from China to Italy to Brazil and around the world to nations such as South Korea, Japan, and the United States.
On March 11, 2020 the World Health Organization designated COVID-19 a global pandemic.
Currently, clinical trials are currently underway for the development of vaccines and therapeutics such as Remdesivir and other antivirals.
While the hope is that COVID-19 will "burn itself out" as SARS did in 2003, Fauci has said that COVID-19 may reappear seasonally, necessitating a vaccine that is at least a year away from being deployed.
The worst case scenarios of COVID-19 are not just bad, they're troublesome. Again, it bears repeating, these are worst case scenario models not base case models. However, there is something to be learned from evaluating these models.
Especially, as Italy seems to be currently experiencing the type of outbreak detailed in these worst case scenarios where decisions about who gets treatment and who doesn't are being made based on age and circumstances. Patients are having to be prioritized as the nation's healthcare system is overrun by patients and is being stressed far beyond capacity. Life and Death decisions are being made in the context of the country's lack of the resources, supplies, hospital beds, respirators, and health care providers needed to tackle their current patient overload. The situation in Italy is heartbreaking. Eerily, Boston's case numbers are similar to those of Italy's just two weeks ago.
German Chancellor Angela Merkel recently stated that 70% of Germany may contract COVID-19.
Based on a presentation by Dr. James Lawler during a webinar hosted by the American Hospital Association (AHA), 96 million people could become infected (in the US alone) with COVID-19 and 480,000 people could die. The elderly being the most seriously impacted with a mortality rate in the mid teens on a percentage basis.
Dr. Lawler served as as a member of the Homeland Security Council for President George W. Bush and as a member of the National Security Council for President Barack Obama.
Separately, Harvard University epidemiologist Mark Lipsitch stated that 40 to 70 percent of the global population could become infected with coronavirus and that it's "almost inevitable" that the virus will reach the "entire globe."
Dr. Fauci advised Congress than millions of Americans could become infected from COVID-19. "If we are complacent and don’t do really aggressive containment and mitigation,” he said, “the number could go way up and be involved in many, many millions.”
Dr. Brian Monahan, the attending physician of Congress and the U.S. Supreme Court, said he expects 70 million to 150 million people in the United States will become infected with COVID-19
According to a recent report by the Wall Street Journal the worst case scenario would mean 10 million deaths worldwide over two years. The best case scenario would see tens of thousands of deaths.
According to Hong Kong's leading epidemiologist, over 60% of the worlds population could be infected and develop COVID-19
Flatten the Curve
Furthermore the healthcare system at large and healthcare workers within the system are likely to be adversely affected as COVID-19 presents an extreme stress test to our ability to handle a pandemic.
Healthcare workers at serious risk from constant and intense exposure to the virus. Dr. Li Wenliang passed at the age of 34. He was the doctor that tried to sound the alarms about COVID-19 in late 2019.
Nearly 3,400 Chinese healthcare workers have gotten COVID-19 thus far and 13 have died according to China's National Health Commission.
The American Hospital Association has posted resources for American Healthcare professionals concerned about the strain on them and the system with the current COVID-19 outbreak growing in the US.
According to Medscape, citing a report from Johns Hopkins Center for Health Security the US healthcare system would not be able to accommodate all the patients needing medical attention under moderate let alone worst case scenarios.
If COVID-19 hits really hard it could lead to 10 million of those needing care also needing a hospital bed — and as many as 2.9 million needing intensive care. The US has about 46,500 medical ICU beds, and another 46,000 could be converted in a crisis — a fraction of those that could be needed in the worst-case scenario, the report warns.
As a result, we collectively need to "flatten the curve" which has become a mantra of sorts for the concerned public and for health professionals.
The basic premise is that if we each do our part in avoiding large crowds, washing our hands for 20 seconds or more with antibacterial soap, refraining from close contact with other individuals, and refraining from touching our face, we may be able to spread out the number of COVID-19 cases over a long enough period of time that healthcare facilities aren't overloaded.
This is key if we want to avoid the heartbreaking gut wrenching choices being made in Italy by a healthcare system that is vastly outnumbered with respect to the number of patients with COVID-19.
The Realistic Threat
Let's say you're a fairly young and perfectly healthy human being. Let's say you get COVID-19 and don't realize it for a week or so because you are asymptomatic for that week. In that week you go out and live your life - you travel for work, you go to a conference, you go to restaurants, you see your friends, you go on dates, etc. During that week you have potentially, unknowingly, transmitted COVID-19 to tens of people (directly) if not hundreds (indirectly). Now let's say some of those people have elderly parents or grandparents that they interact with during their asymptomatic period. And let's say those parents or grandparents interact with their friends of a similar age - perhaps even at religious gatherings or senior citizen centers, or maybe even a nursing home.
It doesn't take much logical and critical analysis to understand how this incredibly practical realistic hypothetical could turn serious and ugly for those seniors and/or immunocompromised individuals.
That's the risk that COVID-19 presents. That's why such intense precautions must be taken here. That's why nations around the globe are putting hundreds of millions of people in a lockdown quarantine.
This is not a joke. This is not a hoax. This is not panic. This is a real risk that people must educate themselves on and for which people must prepare.
Unfortunately, senior citizens are most susceptible to COVID-19 and also the least informed about it's risks.
Seniors are also at risk, during social distancing, of the lasting impacts associate with loneliness, which health officials are calling a social recession. So if you have senior citizens in your family, neighborhood, or social circle, please help them learn the risk of COVID-19 and check in on them while they're taking social distancing precautions.
By now you're all familiar with experts telling you to avoid large gatherings and wash your hands regularly with soap for at least 20 seconds at a time. Try not to touch your face. If you're not feeling well wear a N95 respiratory mask. As soon as you start to feel unwell call a health professional.
A critical component to battling COVID-19 is aggressive testing and preventative measures. Quarantines plus testing, plus preventative measures is a good step in the right direction.
With regard to the masks you may have heard that the surgeon general recently advised people not to stockpile N 95 masks and that only people who aren't feeling well should wear them. That's true, though I will add that I believe every household should try to have a small supply of such masks because should you feel unwell, it will be very difficult to get such a mask when you need it and you risk contaminating others in trying to get a mask when you need one.
However, currently the US has a severe shortage of N 95 respirator masks and it is important that those who are ill, and those health professionals that are on the frontline get access to fitted N 95 respirator masks before healthy individuals who do not have COVID-19.
So what do you do if you have symptoms or you fear you have COVID-19?
What should do you do if you believe you have COVID-19, may have come in contact with someone who has COVID-19, or are exhibiting symptoms consistent with COVID-19?
According to the CDC you should call your physician's office (do not just show up) and/or reach out to a telemedicine professional. They will direct you on how to get a test.
Also wear a mask (if you can get one) and contact your local health department to self identify as a prospective case of COVID-19. For more details click here.
Currently there is a testing bottleneck across the county. On March 13, 2020 measures were announced to speed up testing. Most significantly perhaps is the FDA approval of Roche Holdings AG's new COVID-19 test which projects to speedup testing by tenfold.
Drive through testing has begun to in select areas across the country. I encourage you each to search for drive through test centers in your area.
On Friday March 13, 2020 President Trump also announced that drive through testing will soon be broadly available, though details are yet unclear.
For a list of public health agencies across the country click here
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