Health experts say itâ€™s not a question of whether SARS-CoV-2 will spread within the U.S., but when. A CDC official said yesterday, â€œWe are asking the American public to prepare for the expectation that this might be bad.â€ What exactly does that mean?
The CDC assessment is based on a number of indicators. While the number of diagnosed infections has decreased in China, they have gone up elsewhere. Now for the first time in this epidemic there are more infections being diagnosed daily outside of China than inside of the country. There are infections in new countries that previously did not have any. And the number of infections in certain countries, like South Korea, Italy, and Iran, have increased substantially.
The increase in diagnosed cases outside of China is consistent with community spread of the infection. The infection is spreading undetected, from people with minimal or no symptoms who are shedding virus. Yesterday the first US case was diagnosed in California in an individual with no travel history or contact with a sick person, a classic example of community transmission.
Here we have a virus for which 80% of infections are mild, and likely many more have no symptoms at all. These individuals do not seek medical care and remain undiagnosed. However they are capable of spreading infection.
For all these reasons I feel that excessive concern over SARS-CoV-2 infection is unwarranted. As I wrote above, 80% of infections elsewhere so far have been mild, and it is largely those over 60 who develop serious disease. In contrast, there have been 15,000,000 flu infections and 7,000 deaths this year in the US. No one is worried about those, as only half the population is taking the flu vaccine.
Many people are scared by the â€˜apparentâ€™ 2.3% case fatality ratio. This number is calculated by dividing the number of fatal cases by the total number of diagnosed cases. However, as shown in the table below, the number varies according to age. In those 49 years of age or younger, the case fatality ratio is less than 1%. Furthermore, the number of diagnosed cases is likely to be vastly underestimated. Many mild or asymptomatic infections are not diagnosed. It is possible that the number of infections is actually ten times higher than we detect, which would bring the overall case fatality ratio in the neighborhood of seasonal flu. As I said above, there is little concern about that disease.
Source: China CDC Weekly
No one knows when the virus will arrive in force in the US. It’s amazing that we have had less than 100 cases so far. But if it comes to the US it will spread because we won’t have the movement restrictions that were put in place in China.
What I am worried about is that the administration is not helping the situation. They seem utterly unprepared. Trump has said â€œI think itâ€™s gonna work out fine,â€ and National Economic Council Director Larry Kudlow said that U.S. containment of the virus is â€œpretty close to airtight.â€ These statements are uninformed.
Until two days ago, no single official has been put in charge of organizing the governmentâ€™s response. To make matters worse, in 2018, Trump fired the pandemic response chain of command that the Obama administration set up to address the Ebola outbreak. There is no bureaucracy to coordinate various federal agencies and local responses. This past fall, Trump shut down Predict, a federal program that tracked and researched pandemics.
I would say that the U.S. is less prepared for the SARS-CoV-2019 outbreak than weâ€™ve ever been.
To make matters even worse, Trump has appointed Vice President Mike Pence coronavirus czar. Here is a man who doesn’t believe in science leading the government’s response. Furthermore, while governor of Indiana, Pence fueled the worst HIV outbreak in the state’s history when he ignored the advice of state and federal health officials. He has denied that smoking kills, spread disinformation about condoms, and called global warming a “myth.”
If you donâ€™t think any of this is a problem, listen to the press conference as Trump says â€˜there are 15 cases, then there will be zeroâ€. Then in the same press conference, PHS officials talk about â€˜pandemic preparednessâ€™. It is simply inappropriate and an embarrassment. I think the inherent danger of the SARS-CoV-2 outbreak is not excessive, but it might be in the hands of an inactive administration.
In meantime, I would advise you to ignore the rumors on social media and stick to the facts. Listen to TWiV or read The WHO and CDC websites. Wash your hands often, as the virus is transmitted via mucus (we all touch our nose, eyes and mouth frequently). Stay away from sick people and keep a safe distance from others (respiratory aerosols, which carry the virus, fall to the ground quickly). And if you are sick, please stay home from work and call your health care professional for advice.
“…. it might be in the hands of an inactive administration.”
Inept might be a better word.
We Wait says
“The straight decline in new cases of the virus could be good news, or it could be statistical manipulation. Outside of Hubei, diagnostic test kits are in short supply, and other provinces havenâ€™t switched to using the symptomatic diagnosis now accepted in Hubei. The kits are only being used to test people who came from Hubei and not for cases of transmission, so itâ€™s unsurprising the numbers are dropping. Chinese doctors report that dozens of other hospital patients are being quarantined and treated but not officially diagnosed”
Giuseppe Michieli says
Italy is a classic example of what could happen when an entire country is completely unprepared for an public health emergency. The National Health System, formerly at universal access, was almost dismantled during the Great Depression (2009-2013), so that acute beds shortage are now normal even without disasters. We experiences extreme weather situation (severe and prolonged heat / cold waves) with substantial mortality. Antimicrobial resistant germs are widely disseminated across health infrastructures and IPCs were not consistently applied nationwide (as ECDC said in a ad-hoc mission). Corruption, bribery, incompetency left the remaining of the infrastructure in a derelict state. It is without surprise – so – that Italy became the hot-zone of the European continent, exporting cases everywhere in the world. With more than 20% of population over 65 years of age, with millions of cases of cancer, diabetes & severe comorbidities, rampant poverty, the outcome of this epidemic will be dire. The lesson for those not yet affected is clearly: prepare now, prepare aggressively. There will be another chance.
Chuck Anderson says
“If you are sick, please stay home.”
In an active outbreak and if one is beginning to feel sick, is it better to stay home than to seek medical care?
Chuck, LaGrange GA
Thank you for this level-headed and scientific write up. I wish everyone on social media could step out of the echo chamber for a moment and read this. I appreciate your hard work and your willingness to share with us on your blog. Thank you!
@Chuck: You cut off the second part of the sentence: “and call your health care professional for advice.”
Don’t show up there without prior warning as you might infect the whole doctors office including nurses and other patients. Call them and ask for directions.
Kevin Carney says
TWiV: thank you for remaining rational. News reports seem to be devolving into medievalism. Also, please comment on the many clips on international news (China, Europe) that show fumigation. Is there any evidence at all that can support this practice?
Brian Buchbinder says
I got an email from my urgent care facility. They advised coming in if you were experiencing severe flu-like symptoms. But…
“If you have traveled to China recently, do not go to urgent care or your primary care doctor if experiencing flu symptoms. Report directly to the Emergency Room at your nearest hospital as they are equipped to handle the protocols associated with COVID-19.”
I would caution against suggestions that the fatality is a vast overestimate (and is essentially unknowable). In the case of the Diamond Princess passengers, among the well-monitored sample of 3711 passengers, 705 have so far been diagnosed with COVID-19. Six passengers have died as of today. While this is too small a sample to derive a truly accurate fatality, and while this estimate has to be corrected for age bias based on the population of cruise ship passengers, which skews older than the general population, it still implies that the fatality is at least an order of magnitude higher than for the flu. It is important to be honest about the serious health threat this poses especially to the elderly, for whom the fatality is much higher.
Ernie Chang says
To effectively deal with widespread community dispersion, we are desperate for accurate knowledge of infection rates for asymptomatics, mild symptomatics, severely ill (pneumonia with decreased O2 sats, mortality, prodromal and persistence distributions. A 2% death rate for 300 million is a horrific 6 million, while a 0.2% is still 600,000! But it is irresponsible to minimize and shrug off Covid-19 as flu without real data.
Furthermore, if the severely ill are 5% and the ARDS are 2%, there is a huge gap in facilities and workers for the 6million needing intubation and intensive care.
Going forward, we need accurate figures for facilities planning, appropriate focus and investment.
What NPIs (non pharmaceutical interventions) can do at best is buy time and reduce the rate of community spread while we build capacity and create vaccines and treatments. Holding water in a fist is possible if the temperature is low enough, but only for awhile.
We Wait says
Likely a lot more than flu, but perhaps a lot less than 1918
“Based on these available analyses, current IFR estimates (10,11,12)
range from 0.3% to 1%. Without population-based serologic studies, it is not yet possible to know what proportion of the population has been infected with COVID-19.”
from footnote 12:
“CDCâ€™s reference [IFR] estimate for the 1957 H2N2 pandemic flu (0.1 to 0.3 percent).”
“CDCâ€™s reference [IFR] estimate of 2.04 percent for the 1918 H1N1 pandemic flu.”
We Wait says
“Gates said that its current average estimated fatality rate of around 1% places it somewhere between the 1957 Asian flu pandemic (0.6%) that killed 1.1 million people and the 1918 Spanish flu pandemic (2%) that killed 50 million around the world, according to data from the Centers for Disease Control and Prevention.”
please note says
lets say it’s 2 percent CFR for bad health systems, and 1 percent for first world health systems.
What percentage would it be if we assume that the 20 percent of cases that aren’t mild require hospitalization and this thing spreads as easily if not more easily than the flu, and we only have so many beds and hospital staff?
The paranoid people have moved on from a 2 percent mortality rate so far, and skewed old, to the fact that this thing very easily overwhelms hospital systems.
We’ve had at least one death in korea due to insufficient ICU space… i don’t think the patient even had coronavirus… is that a Covid-19 death or not?
No one said millions would die from this virus. The CDC said our government is unprepared to handle a major pandemic health crisis because of Trump’s anti-science politics have stripped their funding to feed tax cuts to the rich.
That’s the real story here.
Virus Watcher says
How bad it will be does not only depend on the virus but also on the robustness of communities NPI response.
If communities fail to slow the spread enough to prevent hospital capacity collapse, the fatality rate will be much higher.
Every Epidemiologist knows what “slow spread enough” means for a high-R0 respiratory virus like SARSCoV2 without herd immunity nor vaccine.
It means determined, serious, immediate all-out NPI measures like those applied by Chinese Provinces after they learnt the lesseon from the Wuhan-outbreak.
Virus Watcher says
> overall case fatality ratio in the neighborhood of seasonal flu. As I said above, there > is little concern about that disease.
Are you aware of the fact that this implies that China is stupid and/or paranoid to take astronomical socioeconmic costs in an all-out NPI response shutting down meagcities and building new hospitals ?
Virus Watcher says
“Wash your hands often, Stay away from sick people and keep a safe distance from others.”
Commonplace general recommendations …
Completely inadequate against a high-R0, asymptomatically transmissible respiratory pathogen ripping through immunologically naive unvaccinated populations like wildfire.
Its like throwing paper balls against soldiers of an invading army.
(China knows this and acted accordingly from the epi textbook: reduce ALL social interaction and mobility by 1-1/R0 (e.g. 80%) that’s the reason they have now less new daily infection than any other country)
We Wait says
“thatâ€™s the reason they have now less new daily infection than any other country”
Certainly social distancing can slow spread and avoids hospital systems collapse like in Wuhan where case fatality tripled vs. rest of China (as per recent studies based on detailed case progression notes).
But you can’t find what you don’t test for. No one is accurately reporting the scope of infection unless they are testing in the community and that varies immensely in time and place:
1. Large scale testing of exposed populations before symptoms :
South Korea: currently testing 200K sect members
Singapore: local outbreaks led to very extensive testing of contacts
Wuhan: There was a intensive period of extensive testing with a strict deadline date.
Italy: Local authorities tested all exposed people at start of Milan outbreak until central authorities ended the initial practice. https://www.nytimes.com/2020/02/27/world/europe/italy-coronavirus.html
2. Testing of all symptomatic cases with known exposure to specific regions
“Researchers who have examined the genomes of two coronavirus infections in Washington State say the similarities between the cases suggest that the virus may have been spreading in the state for weeks…”State and local health officials have been hamstrung in their ability to test widely for the coronavirus. Until very recently, the C.D.C. had insisted that only its test could be used, and only on patients who met specific criteria â€” those who had traveled to China within 14 days of developing symptoms or had contact with a known coronavirus” case.https://www.nytimes.com/2020/03/01/health/coronavirus-washington-spread.html
TOTAL of new China confirmed cases in latest WHO situation report for China (outside Wuhan and Taiwan): Beijing 2, Hong Kong 1, Liaoning 1
You can’t find what you don’t test for and outside Wuhan testing is limited to cases imported from Wuhan with the natural result that confirmed cases vanished when migration from Wuhan vanished.
Actually, panic may be understandable considering the average age of medical decision makers.
Benjamin Blumberg, PhD says
I offer a home remedy for individuals seriously ill with COVID-19 or flu, based on 20 years of work with RNA viruses. Take a teaspoonful of CsCl mixed in a glass of water (or better, orange juice or tomato juice to hide the saltiness), wait 4-6 hours, then take a half teaspoonful of KCl in water or juice, or eat a banana. CsCl has a serious side effect: in chronic use it causes hypokalemia with attendant cardiac problems, but a pulsed dose should not be problematic. The KCl or the banana is to rebalance the electrolytes (bananas are full of potassium).
plaquenil antiviral says
Good post. I learn something new and challenging on websites I stumbleupon everyday.
It’s always interesting to read through articles from other authors and practice something from