(2019-nCoV (first named); COVID-2019 (later named disease); SARS-CoV-2 (final name of the virus causing COVID-2019):
March 4, 2020 update Part 6
Paul Herscu ND, MPH
This is the sixth, a short piece of writing on the current epidemic. Please read Part 1, Part 2, Part 3, Part 4, and Part 5 for context and also, please read my other writing on this site for a larger context on the overall topic of public health and epidemics.
LASTLY, I am going to deliver a presentation this coming Saturday, March 7th at 3:30 pm at Bastyr University in Kenmore, Washington. This topic is part of a broader course we teach there, but this lecture will be on how to understand and address epidemics in general and this one in particular. Due to the current environment, this lecture is open to all. For more details and to keep up to the moment, please RSVP: http://tinyurl.com/herscu
2019 Novel Coronavirus (2019-nCoV; COVID-2019):
Comments I shared here over the past weeks remain true. I want to highlight a few things here, with the hope that a bit of knowledge will calm the nerves. That said, this will be short so that you can get through it efficiently.
There are five specific points.
First, as I mentioned a few days ago, I was very worried about the exposure of the gentleman who worked in the nursing home. Really, it worried me because of the likely mortalities that would follow, which sadly have come to pass. I want to get back to this point just below, but first let me continue with the points from before.
Second and related, I finally had contact with both the CDC and with the quarantine area in Nebraska which is housing and treating the folks that were on board the Diamond Princess, to recommend they test for C1-INH levels as part of the immune system/inflammatory testing conducted. Hopefully, they will do this, as I believe such information is crucial as a way to save lives. I am not sure this will come to pass, so PLEASE, if you have contacts in the medical world, pass on the request to test patients in critical care for C1-INH.
Third, the ungrounded and inaccurate homeopathic treatment protocols developed by others are not useful. Please do not forward these. An accurate set of guidelines will be developed, but the current recommendations are not based on patient symptoms and are actually simply wrong.
Fourth, regarding the number of cases being reported at this moment, we have a sort of problem understanding the true numbers in the USA. Specifically, the reason has to do with the lack of proper testing, as I mentioned in the very first update last month. That said, the number being used right now for cases is 158 and 11 deaths. But I think this has to be completely wrong if we have 11 deaths, and we use either the mortality rate that WHO is using, around 2 percent or more, or the number I am using, 0.5%, mortality rate. If WHO are right, then we should have around 550 cases, and if I am right then the actual number is really around 2,200 active cases. But in both instances the incidence number is larger than the described 158. (And just as a reminder, as you can read in the first post, when China was describing cases of around 10,000-20,000, we said the number was closer to 75,000, which is what they finally acknowledged.) I think the actual number in the US is somewhere between 550-2,200, right now. One reason we do not know the actual number is we have not had a true sample study done in an area to see how many actually carry the virus but are not symptomatic. For example, in the USA we have tested less than 500 people. In South Korea, they tested well over 100,000, or put in another way, in the USA we have tested 1 in a million, whereas in South Korea they tested 2,000 per million, a stark difference. We need both better testing and at the same time more complete, rapid testing.
Quarantine. I would like to talk about one final piece here, the concept around quarantine, social distancing, self-isolation etc. And I want to start with the most confusing part right off the bat. I know it must seem extremely confusing, frustrating, and maddening to try to understand why it is that people are not just closing down the whole country right now. Why are not all the schools closed, and all public gathering deferred? Why are news conferences still occurring in closed spaces with many, many people there, and hotels still open? Why do restaurants still serve food? And so on. It has to do with risk/benefit analysis of quarantine versus non-quarantine. An epidemic, especially at the start is a very fluid and dynamic time. Closing things down early winds up causing more problems than keeping things going. In short, and this is a big discussion, the main question revolves around Person, Place, and Time. And what may seem appropriate at one time is inappropriate at other times. For example, at this moment, parts of China are loosening restrictions, while parts of Europe are becoming more tightly restricted, and at the same time parts of the USA are becoming hypervigilant and ready to move into action. But the reason municipalities are not being overly restrictive is that the downside of restriction at this time is greater than the upside. And this is coming from one of the first guys who suggested the quarantine in Ebola 6 years ago. I take it very seriously. Here, instead of crying foul and saying that municipalities are not acting correctly, it’s best to understand the fluid nature of quarantine, and that you want to limit disruption in the long term, by acting appropriately, relative to information on the ground, which changes daily. Not understanding that there are also risks to quarantine, has led to food shortages, mask shortages, beatings of people, and ultimately more problems than the virus would cause if we all acted rationally. Or put another way, the sheer health costs to people is worse over time when we over react or react inappropriately.
I want to take one specific example here. At this moment, public health officials suggest limiting large gatherings. Which sounds reasonable until you try to make sense of it and realize you don’t really know what they mean by ‘large gathering.’ For example, how can they say this and at the same time keep restaurants and hospitals and schools open? Here is what they mean, simply. This is a calculation that the more people in a group leads to a higher likelihood that someone may carry this or any other virus, but as I said this is a fluid calculation. At this time, in Washington state, they are asking not to congregate in ‘large groups’ but without definition. What they really meant to say and what we see is that the large marathons and very large concerts, with a cast of thousands are closing, at this time. But in the groups that do not have an identified carrier, groups of scores and hundreds are still meeting. This will change. OVER TIME. If my numbers are right, over the next days, or next week or the week after they will still say that you should not congregate in ‘large groups,’ but then shrink the size of the group they mean to the dozen. We will be able to recognize this time because at that time, whole school systems will close. And if it gets worse, then the group will just be the family. Meaning that restaurants and hotels close. And if it gets worse, then the group is just an individual.
I hope this makes sense. At this point in time, in Washington, more benefit is gotten by going about your day, in a proper hygienic fashion, then by hunkering down. Because if things do go poorly, by the time you should be hunkering down, you would have run out of both tangible and emotional resources and begin to actually cause problems for yourself the rest of the community. What groups like WHO have noted is that improper use of quarantine sometimes adds to the epidemic, adds to emotional turmoil, adds to resource dislocations, and in short, adds to problems, rather than a hopeful solution. As an example, China, got really tight at the worst of it, and then began loosening up so that people can even work in factories of thousands (which is too soon, I think, but you get my point.) And all of this is impacted greatly by having one individual identified which shuts down a particular location.
With this in mind I hope it makes sense what you are reading and hearing. ‘This big event is cancelled…that school is closed because someone is infected…but the school next to it is open as are the others. And that event of hundreds is still occurring.’ When things should be shut down, they will be. Until then, prematurely hoarding and closing causes problems, not solutions. Which is why I start with the header of DON’T PANIC. Panic leads to problems. Always. People need to understand the risks/benefits to premature overreactions to you, your family, and your patients.
In any case, stay tuned!
Paul Herscu ND, MPH