/ Articles / Amid coronavirus concern and cancellations, a case for calm
80 percent of cases mild; elderly most at risk of severe infection
Coronavirus is everywhere, or seemingly soon will be, given its lightning-fast spread across continents and the World Health Organization’s designation of the virus as a global pandemic.
More than 125,000 cases worldwide have been confirmed as of this writing. In the United States, as of March 12, the CDC reported 1,701 cases with 40 deaths in 42 states and the District of Columbia.
The world has responded and reacted accordingly. There is universal advice to wash hands and avoid touching your face; to avoid public gatherings; to work from home when possible; and to avoid nonessential travel. As a result, conferences have been canceled, elections postponed, many universities and colleges have become online destinations only, and sports seasons have been suspended.
Beyond that, however, there are more concerning signs that seem less prudent than panicked.
The stock markets have become roller coasters, and toilet paper, hand sanitizers, and face masks are in short supply as people stockpile the products. In Sydney, Australia, police urged people not to panic after a fight erupted in a store over toilet paper.
In New York, Gov. Andrew Cuomo asked police to investigate the looting of surgical masks from local hospitals. At colleges across the U.S., Asian students are reporting incidents of racism, from verbal insults to isolation. In Iran, 44 people died after drinking toxic alcohol they were told would cure the virus.
A daily dose of bad news has driven public anxiety even more. While the vehicle for transmission is mostly person-to-person contact, researchers now believe airborne transmission is plausible, and the virus can stay airborne for up to three hours. Men are more at risk than women, and the virus takes a deadlier toll on older people and those with chronic conditions and compromised immune systems.
What’s more, according to the World Health Organization (WHO), studies suggest coronaviruses may persist on surfaces such as counter tops for a few hours or up to several days, and that this virus may not go away in warmer weather.
The news could get even worse. Experts are now predicting a surge of cases similar to that experienced in Italy, where in the now lock-downed nation there are more than 15,000 cases and 1,000 deaths, as of this writing. Just three weeks ago there were only three cases.
Sure enough, in New York the number of cases jumped 30% from last Thursday to Friday alone.
Worse yet, common measures people take to protect themselves likely won’t work. Those face masks, for instance, will help prevent the spread of the virus if it is worn by someone who already has it, but a mask won’t protect healthy people from catching it, and there’s no vaccine for Covid-19, its official name, and likely won’t be for a year or longer.
Washing hands and avoiding touching your face are effective, as are avoiding public gatherings and non-essential travel, but those aren’t likely to reassure an anxious public yearning for something more substantial to fight the disease.
The good news
That’s the bad news. Fortunately, as doctors and other health experts who are urging calm have pointed out, there’s a lot of better news, too.
For starters, 80% of those infected will have only mild symptoms, though they may include a cough and fever. The biggest threat is the spread of the disease to population groups more at risk, such as the elderly and those with chronic diseases and compromised immune systems.
In Italy, for example, the number of deaths is high but so is the elderly population — 23% of the population is over 65 years of age. In addition, Italy’s health care system is not as robust as those in other countries. For example, according to a paper published in the Intensive Care Medicine journal, Italy has only 12.5 intensive care unit beds per 100,000 of its population, while Germany has 29.2 and the United States almost 35.
There’s come comfort, too, for elderly patients in their 60s and 70s. According to Italian health officials, the average age of those who have died is 81, many of them with pre-existing health conditions.
The latest studies coming out of China also narrow the greatest risk of death to patients in their 80s or older. In China, the death rate from those over 80 is 14.8%, compared to just 1.3% of patients in their 50s.
That’s not to shrug off the threat to those in their 80s — all lives are important — but that does give clues for the medical community to fashion the best and most appropriate protection for them.
For example, while some civil liberties advocates and even the WHO question general travel restrictions and quarantines, advising the elderly to limit movements and contacts voluntarily and putting restrictions in place to limit social contacts in nursing homes and assisted living facilities may be more reasonable.
Then, too, while many media outlets are pushing headlines about how much higher the death rate for Covid-19 is compared to that of the flu, other experts are cautioning that the current death rate for Covid-19 is likely overstated.
Right now, the stated global death rate for Covid-19 is about 3.4%, and that has drawn comparisons to the early 20th century pandemic of the Spanish flu, which killed at least 50 million people.
The truth is, initial death rates in pandemics are usually overstated. The initial death rate projected for the swine flu pandemic in 2009 was more than 10%, but at the end of the pandemic the true death rate was 1.28%.
Most experts believe the true death rates for Covid-19 are not likely to be even that high. Dr Toni Ho, a consultant in Infectious Diseases at the MRC-University of Glasgow Centre for Virus Research, said the quoted mortality rate of 3.4% was taken from confirmed deaths over total reported cases and that could be misleading.
“This is likely an overestimate as a number of countries, such as the U.S. and Iran have had limited testing,” Ho said. “Hence few of the mild cases have been picked up, and what we are observing is the tip of the iceberg.”
Dr. Mark Woolhouse, professor of Infectious Disease Epidemiology at the University of Edinburgh, agreed.
“The WHO is using the official figure for confirmed cases as the denominator, and this gives the estimate of 3.4%,” he said. “But if a significant number of mild cases have been missed or not reported then this estimate is too high. Though there is disagreement about this, some studies have suggested that it is approximately 10 times too high. This would bring the death rate in line with some strains of influenza.”
Dr. Christl Donnelly of the University of Oxford and of the WHO Collaborating Centre for Infectious Disease Modelling said the infection fatality ratio was the critical number.
“The infection fatality ratio is the proportion of infections (including those with no symptoms or mild symptoms) that die of the disease,” Donnelly said. “Our estimate for this is 1%. This is lower than the observed 3.4% figure because asymptomatic and mildly symptomatic cases are included in the denominator.”
Others observe previous pandemics were more deadly, though much less common, without sparking as much public reaction. The SARS coronavirus killed 774 people out of 8,096 known cases in 2003, a death rate of 9.6%. Again, though, the infection was relatively rare.
Others say South Korea’s Covid-19 death rate might be more reflective of reality. In that nation, aggressive testing is the cornerstone of defense — hundreds of thousands have been tested, and about 20,000 are getting tested every day — and the death rate is much lower than in other countries.
Of 7,398 identified cases as of this writing, 581 people in South Korea have died, a death rate of .07%. Most of those have been elderly people with other medical conditions.
That rate may be more accurate because the aggressive testing of the population has likely captured more of the milder or asymptomatic cases that go unreported in other countries.
Civil liberty restrictions
With Italy on lockdown and the use of travel restrictions and quarantines becoming widespread, civil liberty advocates and some infectious disease doctors are cautioning against overreaction. Such restrictions on freedom can have unintended consequences, they advise.
“Mandatory quarantine, regional lockdowns, and travel bans have been used to address the risk of Covid-19 in the U.S. and abroad,” a group of 450 public health experts wrote in an open letter endorsed by the American Civil Liberties Union (ACLU). “But they are difficult to implement, can undermine public trust, have large societal costs and, importantly, disproportionately affect the most vulnerable segments in our communities.”
Such measures can be effective only under specific circumstances, they wrote, with infringements on liberties proportional to the risk presented by those affected. The ACLU agreed.
“The ACLU will be watching closely to make sure the government heeds these experts’ recommendations, and that its response is scientifically justified and no more intrusive on civil liberties than absolutely necessary,” the ACLU wrote on its website.
In addition, a study by the WHO has itself cast doubt on the effectiveness of travel bans for influenza and other pandemic viruses.
“Extensive travel restrictions may delay the dissemination of influenza but cannot prevent it,” the study stated. “The evidence does not support travel restrictions as an isolated intervention for the rapid containment of influenza. Travel restrictions would make an extremely limited contribution to any policy for rapid containment of influenza at source during the first emergence of a pandemic virus.”
As for quarantines and travel bans, South Korea is also an example of a country taking a less restrictive course, though they have closed schools and encouraged people to work from home and to avoid larger public gatherings.
“Instead of immigration bans and restrictions on domestic movement, South Korea has taken a softer approach to virus containment,” Voice of America reported last week. “Residents wake up to personalized text messages showing new coronavirus cases nearby. They can click on a link that provides detailed information about where the infected patients have traveled.”
The Korea Centers for Disease Control and Prevention has also set up a coronavirus hotline that provides twice-daily updates, in English and Korean, about the latest cases, VoA reported.
Finally, in a Facebook post that went viral and was published by various newspapers as an editorial, Abdu Sharkawy, an internal medicine and infectious diseases consultant with Toronto’s University Health Network and an assistant professor at the University of Toronto, said mass panic could end up being worse than the virus itself.
In the editorial, he said he was concerned but not scared.
“I am concerned about the implications of a novel infectious agent that has spread the world over and continues to find new footholds in different soil,” he wrote. “I am rightly concerned for the welfare of those who are elderly, in frail health or disenfranchised who stand to suffer mostly, and disproportionately, at the hands of this new scourge.”
What did scare him, he wrote, was the loss of reason and the wave of fear leading to stockpiling, and unnecessary stresses on hospitals and urgent care clinics that could crowd out those with serious conditions such as heart failure, emphysema, pneumonia, and strokes.
“But mostly, I’m scared about what message we are telling our kids when faced with a threat,” he wrote. “Instead of reason, rationality, open-mindedness and altruism, we are telling them to panic, be fearful, suspicious, reactionary and self-interested.”
The public should expect that Covid-19 is nowhere near over, Sharkawy wrote.
“It will be coming to a city, a hospital, a friend, even a family member near you at some point,” he wrote. “Expect it. Stop waiting to be surprised further. The fact is the virus itself will not likely do much harm when it arrives. But our own behaviors and ‘fight for yourself above all else’ attitude could prove disastrous.”
Reason and patience were needed, Sharkawy continued.
“I implore you all,” he wrote. “Temper fear with reason, panic with patience and uncertainty with education. We have an opportunity to learn a great deal about health hygiene and limiting the spread of innumerable transmissible diseases in our society. Let’s meet this challenge together in the best spirit of compassion for others, patience, and above all, an unfailing effort to seek truth, facts and knowledge as opposed to conjecture, speculation and catastrophizing.”
Since that post, Sharkawy has also called for no nonessential travel or public gatherings.
Richard Moore is the author of the forthcoming “Storyfinding: From the Journey to the Story” and can be reached at richardmoorebooks.com.