Should you be worried?
You turn on the TV or you read the news on internet and it’s all about the coronavirus. This has led many people to be very concerned about their risk of catching it and to inaccurate information being spread. So, what is the coronavirus? Where did it come from? How serious is it? Is it treatable?
A new type of coronavirus, whose scientific designation is 2019-nCoV, originated in Wuhan, China and is now rapidly spreading to other countries. As of publication, it has sickened more than 37,500 people, killed over 1,000 and reached two dozen other countries. The concern is that it’ll keep increasing and become a pandemic. Recently, the World Health Organization (WHO) announced that the official name for the new coronavirus is COVID-19. The reason they chose this was because the “CO ” stands for corona, the “VI” for virus, the “D” for disease and 19 refers to the year in which the virus first emerged (December 2019). This method of naming was used to avoid stigmatizing a certain location or people, which has happened in the past Middle East Respiratory Syndrome (MERS). Coronaviruses are named for the spikes that come from their surface, which look like a crown or the sun’s corona. They can infect both animals and people and usually cause illnesses of the respiratory tract. These infections can range from something mild, like the common cold, to extremely dangerous, as is the case with Severe Acute Respiratory Syndrome (SARS) and MERS. There is still a lot unknown about COVID-19, but it’s thought to have crossed from animals to humans. The initial cases were linked to a market in Wuhan that sold live fish, animals and birds. The reason the source can’t be identified is that the market was shut down and disinfected, which makes it nearly impossible to investigate. One possible source are bats because they have evolved to coexist with many viruses, including coronaviruses. However, it’s very possible the virus was transmitted from bats to an intermediate animal before being transferred to humans. SARS is also are thought to have emerged from live animal markets and MERS is transmitted to humans by camels.
The symptoms for COVID-19 include fever, severe cough, difficulty breathing and shortness of breath. Some people have reported having gastrointestinal problems and diarrhea as well. Milder cases usually are similar to the flu or a bad cold, which makes detection difficult. The incubation period is thought to be 10 – 14 days. If the illness becomes severe, it causes lung lesions and pneumonia. If you develop pneumonia, then you’re at greater risk of having systemic inflammatory response, a hallmark sign of a serious viral disease. During this inflammatory response, your lungs, heart, liver, kidneys and the systems that control blood clotting are all impacted, though the reason it does this isn’t clear. The bad thing is that heightened inflammation from diseases, like the flu, will often last for at least a month after the acute illness is gone. This increases the risk for heart attacks and strokes in older people, especially those with underlying health problems, such as diabetes, heart disease or cancer. One especially concerning factor with COVID-19 is that some patients who at first appeared mildly or moderately ill are taking a turn for the worse several days or even a week into their illness. This is why experts say the situation needs to be carefully monitored and it’s not safe to assume that someone who seems to be doing well early on is out of the woods. According to the WHO, about 20% of reported patients in China had developed severe illness from COVID-19 and about 2% had died. However, since many infected people only have had mild symptoms and not sought medical care, this would mean the overall fatality rate is actually lower. One alarming thing that has been discovered about COVID-19 is that infected people may transmit the virus to others even before they experience any symptoms. This fact means that it makes controlling the spread of the virus much more challenging. The good news is that relatively few children appear to be developing severe symptoms so far. While younger people are getting infected, they’re experiencing milder symptoms. This same pattern was seen in outbreaks of SARS and MERS, too. The MERS epidemics in Saudi Arabia (2012) and in South Korea (2015) together claimed more than 800 lives, but most of the children who were infected never developed symptoms. Similarly, no children died during the SARS epidemic of 2003, which infected 8,000 people with the majority of the 800 deaths being people over age 45, particularly men. Looking at the published reports for the SARS outbreak, researchers at the Centers for Disease Control (CDC) identified 135 children who were infected. According to the data, children under age 12 were much less likely to be admitted to a hospital or to need oxygen or other treatment, whereas children over age 12 had symptoms very much like adults. This type of impact disparity isn’t unusual for viruses. They often trigger only mild infections in children and much more severe illnesses in adults. Chickenpox is a good example of this. Adults may be more susceptible because they’re more likely to have other diseases that weaken their immune system, which makes it difficult to fight off infections. Also, as we age, our body’s innate immunity begins to decline, especially after middle age. A key question that still needs to be answered about COVID-19 is whether children who are infected and asymptomatic are able to pass the virus to others because this could contribute greatly to the spread of the virus. There is a diagnostic test that was developed by the CDC based on genetic information about the virus provided by the Chinese authorities is being used to test for COVID-19. The test has been approved by the Food and Drug Administration (FDA) and will be distributed to state laboratories.
Since COVID-19 is a virus, the main treatment is supportive care, which means any infected person should rest and drink plenty of fluids. In addition, it’s essential to make sure the person is getting enough oxygen and, if necessary, using a ventilator to push air into their lungs. There aren’t any medications designed specifically to treat COVID-19 or any other coronaviruses. The WHO said despite several reports and claims of breakthrough research on the treatment front, there remains no known treatment for the disease. In an effort to improve patient outcomes, Chinese officials are experimenting with other antiviral drugs to treat the infection. Hopefully, there will be some relief soon because Gilead has started clinical trials of an experimental drug, remdesivir, on infected patients in China. Many organizations, including the National Institutes of Health (NIH), have begun work on vaccines, but it’s still too early to have any real results. Researchers are using work already done on vaccines being created to combat the SARS and MERS viruses in order to jump start the efforts on a COVID-19 vaccine. This is crucial because after the SARS outbreak, it took researchers about 20 months to get a vaccine ready for human trials and since the disease was contained, the vaccine was never needed since the outbreak ended. By the time Zika appeared in 2015, researchers were able to bring the vaccine development timeline down to six months.
Both the WHO and US have offered China technical assistance and expertise to investigate and contain the outbreak. The WHO has recently declared COVID-19 a “public health emergency of international concern.” This wasn’t an arbitrary decision because they consider three factors before giving that designation. These factors are is the outbreak unusual or unexpected, does the outbreak have implications for health beyond a national border and does the outbreak require immediate international action? The answer to all of these in relation to COVID-19 is yes. When there is a sudden increase in the number of people with a particular disease in a limited area or there is an emergence of a usual type of disease, it’s considered the onset of an outbreak. If an outbreak expands to a broader population, it becomes an epidemic. However, epidemics can be severe without ever rising to the level of a pandemic, so long as they mainly affect one region. The CDC defines a pandemic as one that has spread to several countries/continents and usually affects a large number of people. The severity of illnesses nor number of deaths aren’t considered factors in making this distinction. This is what’s going on with COVID-19, so far, but as we learn more about the virus, likelihood of it becoming a pandemic is increasing. If the number of cases in Europe and the US drastically escalate with no clear ties back to China, then it would be called a pandemic. MERS never made it past the epidemic stage, but SARS earned pandemic status because it affected 26 countries and had ongoing chains of transmission. There is some thought that COVID-19 could end up following the path of the H1N1 swine flu. It caused a pandemic in 2009 that subsided in 2010, but the virus continues to circulate as one of the primary strains of the seasonal flu. If this happens with COVID-19, it could lead to tens of thousands of deaths in the US each year.
A new study published in the Journal of the American Medical Association (JAMA) reported that of the first 138 patients diagnosed at one hospital in Wuhan, 41% were presumed to have been infected in the hospital, which means that nearly half of the initial infections were spread within the hospital itself. This is known as nosocomial transmission. Initially, there was some speculation that some of the spread was the result of a “super-spreader,” which is when one person transmits an infection to many other people. This is what led to considerable transmission of MERS and SARS inside hospitals. While this would’ve been concerning, it’s not nearly as much as what appears to have happened, which is that many healthcare workers and patients got infected in many parts of the hospital because the virus is spreading rapidly throughout the building. Healthcare workers are particularly vulnerable, so they must be protected. There are a variety of ways to do this, including a hierarchy of controls: source, engineering, administrative and personal. Source controls are encouraging people who are only mildly ill to not expose others, requiring all people who are ill to wear face masks, limiting visitors who may be infectious, making sure that ill healthcare workers don’t work and decreasing the number and risk of certain procedures, such as bronchoscopy and sputum induction, by performing them only as absolutely necessary in isolation rooms. Engineering controls would be putting partitions in triage areas, not recirculating potentially contaminated air and meticulously clean all surfaces. Administrative controls mean asking all patients if they have any symptoms and taking their temperatures, requiring any with a cough or fever to wear a face mask and isolating any ill persons from others at least by several feet until they’re more thoroughly assessed. The key component is to recognize all potentially infectious people quickly and to implement strict infection control procedures early in all areas of all healthcare facilities. Personal controls apply to the individual and include frequent and thorough hand washing and respiratory hygiene (ex. covering your mouth when you cough or sneeze). Mask use by people who don’t have symptoms and aren’t caring for others receive little or no benefit from wearing them. The risk comes from those who need masks can’t get them because they’re in short supply from people buying them that don’t need them. The people who need them the most would be healthcare workers and those caring for ill patients.
Once the threat was recognized, China took drastic actions to bar people from leaving affected areas, but 5 million people departed Wuhan before the restrictions went into effect. Globally, governments have been screening incoming passengers from China for signs of illness and some have even banded people coming into their country from China. The US State Department has warned Americans not to go to China unless it’s absolutely essential and there currently isn’t a travel ban for Americans, but foreign nationals who have recently visited China are not permitted to enter the country at this time. As a result of the outbreak, many airlines have canceled flights to China. It’s important to note that any Americans who are returning home from Wuhan and Hubei Province are being quarantined for two weeks. US officials have defended this response by saying they’re taking necessary steps to prepare for the virus and slow its spread with this being one of those steps. The latest travel restrictions could stop hundreds of thousands of people from visiting the US each month and result in huge economic and societal impacts. Some experts say that the ban is very restricting with very little evidence that it’s actually going to provide any benefit because all of the data available indicates that travel restrictions and quarantines directed at specific countries are unlikely to keep the virus out of our borders and will only exacerbate the epidemic’s social and economic tolls. The director-general of the WHO commented on this by calling on countries not to impose travel restrictions since there are variety of ways it can backfire. Some of these ways are that individuals are more likely to lie about how they’re feeling, governments might hold back and not share information about COVID-19 in their countries, especially if they feel they’re being punished if they do, and it makes it harder for health personnel to get into an affected country to provide the aid that is needed. The economies of the affected areas also suffer because other countries don’t buy what they’re producing. So, the WHO’s director-general has asked that countries who’ve implement travel bans to keep them short in duration, proportionate to the public health risks and regularly reconsider them as the situation evolves. Another concern is that historically a large number of these border security measures use public health as a pretext for discrimination to prevent immigration for whatever reason. The bans for COVID-19 could be occurring in this particular international political climate.
For the time being, the risk to Americans is low. As with most respiratory viruses, COVID-19 is transmitted through coughing and sneezing. This means you should wash your hands frequently and thoroughly, avoid touching your face and try to stay away from anyone who is coughing or sneezing. As far as surgical masks go, they’re not closefitting enough to filter all the air you are breathing in, which means they aren’t going to protect you. The heavy-duty N95 respirators offer better protection, but they’re extremely uncomfortable and you must get the right fit in order to receive the benefit. If you must travel to an area that is impacted by the virus, the CDC states you should follow enhanced precautions, like avoiding contact with anyone who is sick, staying away from animals and the markets in which they are sold and refrain from eating raw or undercooked meats.
The majority of people are able to fight off a COVID-19 infection without any major issues and only a small number of people are at risk of developing life-threatening complications. By following the recommended safety practices of frequent and thorough hand washing and the proper respiratory hygiene of covering your mouth when you cough or sneeze, you’ll greatly decrease your chances of contracting the virus. If you’re feeling sick, stay home to decrease the chances of spreading your illness to others. COVID-19 is something that we need to take seriously and monitor closely, but is not be something that we should panic about.