Coronavirus Update 2
March 16th, 2020
SARS2 Severe adult respiratory syndrome coronavirus is the viral name
COVID 19 is the disease name
Preamble note: 99% of us are not at risk for a bad outcome. Take solace in that notion. Please do not use that as a license to be cavalier with other people's health.
What a difference a week can make! For good reason, we are heading toward lockdown here in North Carolina in an effort to contain the rapid spread of the novel coronavirus. Primary and secondary schools have suspended all sporting events, major professional sports are on hold and all conferences are being postponed. In the last 24 hours, NC public schools will close and go online for a while if not the remainder of the year. All of this is a last ditch effort to control what is likely uncontrollable.
Why it matters? I have been fielding lots of why questions.
It appears that the virus is spreading more rapidly than the CDC and other entities predicted and may overwhelm our medical system in coming weeks. Despite the fact that asymptomatic and lethality statistics remain the same from my last email, the rapid spread will bring a lot of disease to our elderly and that is where everything goes south. If the current lockdown plan works and that is a big if (at great economic and emotional cost), we may yet save many elderly lives that could otherwise follow the Italian debacle to their triage demise based on available health care. Yes, this is really happening in Italy. They are having to decide whom to keep alive and who to let die because they do not have enough intensive care space and the necessary ventilator machines for the surge in patient illness. As a physician, that thought is a nightmare to entertain.
Social distancing and quarantining is exactly what great societies do when faced with an infectious agent that is trying to take out the wisest and oldest among us. We make the hard decisions for those that cannot. It is that time folks.
This is a really infectious virus. According to Dr. Peter Hotez, the current data says that the virus appears to have an R0 of between 2.5 and 3. This is an indicator of how fast the pathogen spreads between persons or the reproduction number, which is defined as the average number of secondary cases generated per infectious person. That is fast. Influenza has an R0 of 1.3 while the measles virus carries and R0 of 12. (Biggerstaff et. al. 2014) There is also some emerging evidence that the virus can be spread through stool from asymptomatic children, akin to hepatitis A. That fact adds another layer of infectious spread among the very young and the very old. This is another reason why hand-washing is critical.
The biggest problem as I see it at this point is that we are still only testing the known exposures and the foreign travelers when we know that it is already here and likely in big volumes. The known exposures are still minimal so far. We will never get an accurate containment until we start testing anyone with symptoms and their contacts once we know that they are positive and then begin quarantine. We need a more accurate denominator. We only have a slice of the numerator. This is not the way to handle a pandemic. Korea had the right idea with testing hundreds of thousands of people with drive through testing to more accurately quarantine COVID positive people even when they are mildly or not ill at all. This is likely the entire 0-18 year old age group. South Korea and China applied these aggressive measures and have passed the inflection point in new cases. Contrast this with Italy which did not apply these methods for identification or containment. According to Dr. Attia, South Korea has a mortality rate of 0.68% while Italy is at 6%. That is a 10X increase in death. This clearly tells us that we missed the boat on containment in the US because w are not acting like South Korea. We are not doing what we need to do to contain this illness.
This may sound like a lot of doom and gloom. But it is really only so for the elderly or those with hypertension, diabetes and other chronic disease. For all the rest of us it is a wake up call to be ready to protect those that cannot protect themselves. Be ready to self quarantine in the future and socially distance now. It is our civic duty to not travel if you have recently been sick even if the system will not test you! Make the hard choice now knowing that you could be saving a life. Remember that the 0 to 20 year olds are mostly asymptomatic but can still spread disease.
Further data has emerged:
1) WHO early reports note that roughly 80% of infected individuals are asymptomatic or mildly so making this a very hard virus to detect and quarantine unless we test the mild cases. Hence the reason we are here in the first place. SARS2/COVID-19 is the perfect storm of severe infectivity (worse than the flu) and mild but significant mortality for most allowing it to spread far and wide. In other words, most people are highly infectious but do not know that they are so they are carrying it all over the place. This is a mess.
2) In a study from the Chinese COVID experience from mid January published yesterday in the NEJM we see some childhood statistics finally. Of 365 children admitted to the hospital for an illness, 43 had influenza while 6 had COVID - 19. No one died. And median hospital length of stay was 7.5 days. (NEJM Article)
3) From a Chinese epidemiological analysis: 72,314 cases analyzed, 86.6% were over 30 years of age. 80.9% were considered mild. (Zhi et. al. 2020)
4) Medical personnel are getting infected at a relatively high rate putting them on a multi week quarantine. This may have very serious consequences to the medical system that is needed to care for the sickest patients.
5) This site has the best information about the presentation of the virus
6) Viral particle survival outside the human host is of great importance to knowing how you can become infected. In an article by Van Doremalen and colleagues new have some data. They looked at SARS1 versus SARS2 on four different surfaces, copper, plastic, cardboard and steel. The virus SARS2 can last on copper for 8 hours, cardboard for a day, steel for 2 days and finally plastic for 3 days. That is a long time for a virus to wait for someone to come by touch the object and then touch their face. Hand washing anyone?
The to do to keep your immune system strong and prevent disease spread:
1) Practice social distancing no matter how old you are
2) Eat super healthy - no processed food
3) Get 8 plus hours of sleep per night
4) Think positively
5) Mildly exercise daily
7) Eat asian mushrooms, cruciferous vegetables, red/orange/yellow peppers and small oily fish daily
8) Drink lots and lots of water
A final reiterated note: 99% of us are not at risk for a bad outcome. Take solace in that notion. Please do not use that as a license to be cavalier with other peoples health.
Stay tuned - I plan to have a midweek newsletter on further changes,
NEJM Coronavirus History Article
NEJM Child Analysis
AAP Video for Parents
Biggerstaff BMC ID Article
Zhi Pubmed Article
Heyman Lancet Article
CDC Clinical Presentation Page
Peter Attia Show Notes Page
Van Doremalen Transmissability Article
• Information from the CDC for health care professionals, http://bit.ly/2VMAxi6
• Information from the AAP Red Book, http://bit.ly/38mUY7S
• AAP policy Infection Prevention and Control in Pediatric Ambulatory Settings, http://bit.ly/39EAZ66
• Information for parents from HealthyChildren.org on coronavirus, http://bit.ly/2PNTuwX and talking to children about disasters, http://bit.ly/3arJbXj