Image by Gerd Altmann from Pixabay

March 9, 2020

Coronavirus COVID-19 continues to get a ton of attention in the national media. The sensationalism of it all is a bit hard to swallow. It is a serious issue, but the way it is being portrayed is a bit beyond the pale. In a recent opinion piece by David L. Katz in the New Haven Observer, we see a modicum of tempered realism in this sea of media sensationalism. I highly encourage everyone to read this entire piece. Following the traditional media is not the best idea at this point, instead follow the Center for Disease Control.

Here are some of the highlights from Dr. Katz's piece:

"One thing you learn in medicine is that we control ship and sail, but never wind and wave. We don't control everything, ever. Bad things happen to good people doing everything right all the time. But they do happen much less often to those doing everything right than to everyone else, so what we do matters enormously. It shifts probability. So, the questions about coronavirus revert to questions about probability. And those we can answer, or at least - establish the basis for answers."

"Here's an important reality check: we are much, much more likely to overlook the mildest cases of any disease than death from that disease. Death is hard to miss.

What would it mean if this common scenario pertains to COVID-19? It means many more people than we know are getting the infection, but with mild symptoms passing for a cold, or maybe even no symptoms at all. The "bad news" here is that the infection rate might be much higher than we think. But does that increase your risk of getting the disease (yes!), and dying from it (no!)? I'll illustrate.

Let's say you are a member of a hypothetical population of 2,000 people. We believe this population was exposed to coronavirus, that 200 people got infected, and that 8 died.
The infection rate here is (200/2000) or 10 percent (much higher than the reality in Wuhan), and the fatality rate is (8/200), or 4 percent (about what has been seen to date in Wuhan). If you are a typical member of this population, your risk of both getting the infection and dying from it is {(200/2000) X (8/200)}, or 0.4 percent. We can see this directly from the total population numbers: 8 deaths out of 2000 is, just as our calculations showed, 4 deaths per thousand, or 0.4 percent. And to flip this around, it means your chances of dodging the coronavirus bullet are 99.6 percent. Those are good odds!"

"But what if we were wrong - not a little, but a lot- about the number of infections, because we had overlooked many that were too mild to attract anyone's attention? Well, then, maybe 4 times as many actually got infected, 800, rather than 200. This does mean you are much more likely to get the virus yourself, but does that make it more likely you will die from it? Not at all. The simple math shows why.

We now have an infection rate of (800/2000), or a very alarming 40 percent. But we now also have a fatality rate of only (8/800), or 1 percent. If we repeat the prior calculation for your personal risk of getting the virus and dying from it, we have: {(800/2000) X (8/800)}, or...the exact same 0.4 percent as before.

This is true of coronavirus in the real world. If we are finding every case, then your risk of getting infected is, for now at least, very low, and your risk of dying if you do is also very low. If we are missing a lot of cases, your risk of infection may be much higher, but your risk of dying if infected is commensurately lower. It's a zero-sum game, and each sum, for now, means a very low probability indeed that you or someone you love will die from this disease."

Let me put all of this in perspective. If you drive a car, what is your risk of dying? A plane? When you run the statistical analysis, it is orders of magnitude more dangerous to drive a car than fly in a commercial airplane. Yet, when you poll people, they rarely if ever fear the car, but often fear the plane. This is clearly illogical, but humans often live in the emotional world and not the logical one.

I say this because as with Dr. Katz, I believe that many people are treating this reality with coronavirus as a scourge of significant orders of magnitude higher than what it currently appears to be, a trouble maker inline with Influenza or maybe a little worse. It is not good but also not the end of the world. Influenza and now coronavirus, COVID-19 are nasty viruses that carry significant risk to certain groups and these groups need to be protected by society and individuals in general. I have an 84 year old father with CAD and significant risk factors, so I am all over this disease.

The real dilemma with all of these respiratory viral illnesses is that they disproportionately affect certain populations increasing their risk of a bad outcome. From the CDC:
Early information out of China, where COVID-19 first started, shows that some people are at higher risk of getting very sick from this illness. This includes:
• Older adults
• People who have serious chronic medical conditions like:
o Heart disease
o Diabetes
o Lung disease
If you are at higher risk for serious illness from COVID-19 because of your age or because you have a serious long-term health problem, it is extra important for you to take actions to reduce your risk of getting sick with the disease.

According to the CDC if you are at high risk:
• Have supplies on hand
o Contact your healthcare provider to ask about obtaining extra necessary medications to have on hand in case there is an outbreak of COVID-19 in your community and you need to stay home for a prolonged period of time.
o If you cannot get extra medications, consider using mail-order for medications.
o Be sure you have over-the-counter medicines and medical supplies (tissues, etc.) to treat fever and other symptoms. Most people will be able to recover from COVID-19 at home.
o Have enough household items and groceries on hand so that you will be prepared to stay at home for a period of time.
• Take everyday precautions
o Avoid close contact with people who are sick
o Take everyday preventive actions
 Clean your hands often
 Wash your hands often with soap and water for at least 20 seconds, especially after blowing your nose, coughing, or sneezing, or having been in a public place.
 If soap and water are not available, use a hand sanitizer that contains at least 60% alcohol.
 To the extent possible, avoid touching high-touch surfaces in public places - elevator buttons, door handles, handrails, handshaking with people, etc. Use a tissue or your sleeve to cover your hand or finger if you must touch something.
 Wash your hands after touching surfaces in public places.
 Avoid touching your face, nose, eyes, etc.
 Clean and disinfect your home to remove germs: practice routine cleaning of frequently touched surfaces (for example: tables, doorknobs, light switches, handles, desks, toilets, faucets, sinks & cell phones)
 Avoid crowds, especially in poorly ventilated spaces. Your risk of exposure to respiratory viruses like COVID-19 may increase in crowded, closed-in settings with little air circulation if there are people in the crowd who are sick.
• If COVID-19 is spreading in your community, take extra measures to put distance between yourself and other people
o Stay home as much as possible.
 Consider ways of getting food brought to your house through family, social, or commercial networks
Knowing all of this is predicated on the fact that this virus maintains its current trajectory. If you spend any time in medicine, you learn that change is not only inevitable but expected.

From the NEJM Journal watch: "The researchers studied nine young- to middle-aged adults in Germany who developed COVID-19 after close contact with a known case. All had generally mild clinical courses; seven had upper respiratory tract disease, and two had limited involvement of the lower respiratory tract. Pharyngeal virus shedding was high during the first week of symptoms, peaking on day 4. Additionally, sputum viral shedding persisted after symptom resolution. The researchers say the current case definition for COVID-19, which emphasizes lower respiratory tract disease, may need to be adjusted." (Herman A. NEJM Journal Watch 3/10/20)

The statistics appear very clear so far that the coronavirus is hitting the elderly and not the young. It appears that almost no children below the age of 14 years old are significantly affected although they will get mildly infected and spread it. Minor events are occurring in the 15 - 30 year old range. Serious cases start to emerge in the 30's but are rare and don't really appreciably pick up until the 50's. Peak disease risk is in the late 70's and onward. Having cardiovascular disease, hypertension, diabetes or immune system issues really raises a person's risk of a bad outcome. There is a lot of information to unpack here. The data will continue to mutate and evolve and we must be ready to shift and change behavior in accordance with the recommendations of CDC and your state Health Department. The CDC and your state Health Department's website are the BEST place to get your information. I would avoid the sensational media for now.

I will leave you with this note. If you have been following this newsletter over the years and practicing healthy lifestyle choices on a daily basis, then it is almost certain that your risk probability will be far less than if you practiced the opposite. Keep eating well, sleeping often, meditating, relaxing walking and doing what you do. Be grateful for this glorious life that we lead and try and stay grounded in logic about these viral diseases. Practice precautions as directed by the CDC and know your personal risk.

We will follow this disease together as it unfolds.


Dr. M

Katz Coronavirus Article
CDC Site
NEJM Coronavirus Site