March 26, 2020
THIS IS A LONGER NEWSLETTER! I FELT THAT IT WAS NECESSARY TO PRODUCE A FULL PICTURE AND PREVENTION STRATEGY
Preamble note has not changed: 99% of us are not at risk for a bad outcome. Take solace in that notion, however, the sand is changing under our feet. Early data out of China is showing that the case fatality rate is significantly less than originally thought, but the US data is emerging and appears to be different with a downward trend difference for age at diagnosis but not death.
Please do not use any of the following information as a license to be cavalier with other people's health. See the later articles about fear and prevention of mental stress.
The emerging United States experience is shifting from what was seen in the early days of the pandemic overseas. The reason is unknown. It is showing that more younger individuals are getting sick with minor to significant disease although death is still skewed heavily toward the greater than 65 year olds and exceedingly rare (one unconfirmed) death under 20 years old as of this writing. This emerging data set is different than what the Wuhan China and South Korea experiences were. Men and dying at a significantly higher rate than women at roughly a 2:1 ratio. There has also been speculation that the American youth are at higher risk for COVID symptoms because of increased metabolic abnormalities, cigarette smoking and vaping that has pervaded the American society in recent years. This is likely why men are dying at higher rates as well. Smoking is believed to increase the the ACE2 receptor that is used by the SARS2 virus to infect the type 2 pneumocyte. This is hypothetical at this point. On that same line of thinking, there are millions of asthmatic Americans. I have not seen any data that having asthma is a risk factor for a bad outcome which is very reassuring. However, the major concern is that if this data changes, asthmatics could be at risk based on lung inflammation. Therefore, I STRONGLY recommend anyone with asthma take their inhaled corticosteroids as recommended by your provider of care. This is likely to save many lives if the illness becomes more problematic for asthmatics.
As we discuss and look at the emerging data, remember three things. 1) It is changing real time and lightning quick 2) Don't hold any of theses truths to tightly as change is inevitable. 3) Be aware that a large portion of the media presentation is fear promoting and not statistical truths as the denominator of cases is still nowhere in the United States data set making true death risk unknown. I will present the data and my opinions about it knowing that these are hypotheticals and not set in stone. Time is the only harbinger of truth. I cannot state this strongly enough. Most of you are currently at extremely low risk, keep fear suppressed while you absolutely practice safe activity especially if you are over 60 years of age.
Knowing all of this, what is the new data. Let us look at the Diamond Princess cruise ship as this data set is the purest experiment of transmission and risk of death as these people were forced to quarantine together for weeks. 3,711 people were on a cruise ship from February 3rd for 4 weeks. There were just over a thousand crew members on board of the 3,711 total passengers. They were rapidly quarantined after the first crew member tested positive after the cruisers were quarantined already. By quarantine ending, 20 crew members tested positive for COVID and none died. Of the passengers infected, the transmission was significantly reduced by strict isolation quarantine leaving over 300 people infected and another 300 plus positive but asymptomatic. (CDC MMWR)(Nishiora 2020)(Mizumoto 2020)
From Science News, the authors looked at Tim Russel's data and had this statement: "As of February 20, tests of most of the 3,711 people aboard the Diamond Princess confirmed that 634, or 17 percent, had the virus; 328 of them did not have symptoms at the time of diagnosis. Of those with symptoms, the fatality ratio was 1.9 percent, Russell and colleagues calculate. Of all infected, that ratio was 0.91 percent. Those 70 and older were most vulnerable, with an overall fatality ratio of about 7.3 percent."
"Extrapolating those numbers to China, the team estimates that 1.1 percent of symptomatic cases there turned deadly. Considering asymptomatic cases drops that ratio to about 0.5 percent in China, the team calculates. " This fatality rate mirrors South Korea's early numbers.
What this says is that under effective quarantine and testing measures, death rate is significantly less than 1% which is worse than the annual influenza data but not by much as influenza has an annual kill rate around 0.1%. Italy and other European countries are showing vastly different outcomes based on lax early quarantine measures and overwhelmed health care systems versus full testing and quarantine. Italy and Spain are north of 8-10% death rate without having an accurate denominator as they did not put in effective testing or subsequent quarantine measures as was the case in Germany. Germany has done an effective job and has a very low death rate. Unfortunately, the United States health system has not followed the lead of the effective countries. We are continuing to not test enough individuals to know who to quarantine aggressively. We are on the wrong pathway and the United States government and healthcare systems are trying desperately to avoid catastrophic increases in the urban city centers like New York City where the risk is highest by going into full stay at home lockdown. Time will answer the effectiveness of this strategy.
Back to the age predilection issue. It is still abundantly clear that being over 60 and even more so over 70 and/or having hypertension, diabetes mellitus, metabolic syndrome or chronic lung disease puts you at high risk for morbidity and mortality. Looking at the Evergreen Hospital data from Washington state, we see the mortality play out with adults that have significant preexisting conditions. (Arentz et. al. 2020)
US data out of New York City is showing a significantly younger age distribution. According to CNBC, 48% of the positive COVID patients are younger than 45 years old but only account for less than 3% of all fatalities. Only 2% of all cases are under 18 years old in NYC. (CNBC Webpage)
The take home point to all of this is: If you are over 60, you need to quarantine yourself 100%. If you are under this age threshold, then hopefully the quarantine in place rules are effective and then loosen over time and one of two things happens: 1) the virus burns out or 2) the majority of us get exposed, immune and have protection for the elderly as time goes on, otherwise, these events could restart if the virus does not fully disappear globally which seems very unlikely at this point. There is clearly a very small but real risk that some people under 50 years of age will have a negative outcome. Thus, everyone will have to weigh and measure choice based on the governments future positions on quarantine. I stress that we all need to be very aware that those individuals under 50 years old are getting ill with some frequency but they are mostly avoiding death. Death rate in the United States to date is much less than 1% from 20 to 50 years old and almost zero under 20 years old as of the writing of this piece. Read this Vox article for details of US age related data from March 23rd.
As of March 25th, the US data is more than 54000 cases defined and 737 deaths which is a death rate 1.4%. Again, this is a case rate without a true illness denominator. This is only based on those tested which is likely a small fraction of those ill and asymptomatic making the death rate likely far lower by orders of magnitude. The current cases identified are clustered in major metropolitan areas which is not surprising as close contact is the greatest risk factor for contraction of COVID.
In my opinion, the best path moving forward would be a hybrid of mega testing anyone ill (which we are not doing and was show to be very effective in South Korea, Germany and China) or a close contact of an ill person with mandatory 2 week quarantine afterwards coupled with full quarantine of all at risk individuals based on age and disease comorbidity to prevent overwhelming the healthcare system until such time as we have the infrastructure in place to handle the COVID lung disease. This is likely imminently necessary in the big city centers where exposure risks are high and exponential spread is possible. The dance that the federal government has to attempt is daunting. How do you limit a catastrophic death rate while not destroying people's lives economically in the process? I am glad that I am not the decision maker as it is a lose lose at this point.
Here is the downloadable document from Az IM department: Link. It is an excellent document.
SARS2 Severe adult respiratory syndrome coronavirus is the viral name
COVID 19 is the disease name