Coronavirus Myths Debunked-Episode 2

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[This post was updated on 3/12/20. This is NOT the most recent blog in this series. My current thinking on this issue is better reflected by the Dan Bongino interview in Episode 4 or Episode 5 which covers the urgent need for us to begin to take steps to avoid the overload of our health systems. Meaning while the opinions expressed in this blog are still backed by data, the catch is that to have lower mortality rates we need to shut down our society due to our lack of ability to test for the coronavirus at scale as of the week ending 3/13/20.].

As a physician, I’ve posted on the coronavirus two times this past week to try to answer the bevy of patient and family questions I have received. My second post was shared very widely and generated lots of comments from many freaked out and frightened people. Hence, I’ve taken the biggest misconceptions I have seen in those comments and in the media and reviewed them with this post.

Please Don’t Panic!

I have to say, that after being a doctor for 31 years, I’m not sure that I’ve seen anything quite like this level of abject panic regarding a respiratory virus in my career. While this is a bad bug that can overwhelm health systems and should be taken seriously, the misinformation is spinning out of control. Again, if you focus on the actual hard data, it paints a different picture.

As of this morning, we have just over 4,000 deaths worldwide. Again, the average seasonal flu kills between 291,000 to 646,000 people worldwide each year (15). The CDC just announced that the US had 20,000 flu deaths this season with 350,000 hospitalizations (16). Today, on average, 48,219 people will die of cardiac disease (17).

So why the abject panic? It’s being fueled by some in the media. As I’ll show below, when you have trusted names like Sanjay Gupta fanning the flames of fear rather than correctly interpreting data, you can see why people are so freaked.

My Top Coronavirus Misconceptions List

  • The mortality rate of coronavirus is 2-3%! 

This has been reported many times. Most recently by Sanjay Gupta who should know better. At a White House press conference, Dr. Sanjay Gupta said, “the flu has a fatality rate of about 0.1%, this has a fatality rate of somewhere between 2-3%…”

COVID-19 DOES NOT have a 2-3% mortality rate. That number comes from the Chinese Wuhan data. The issue is that that number represents mostly sick people tested for the disease versus total deaths. Regrettably, that’s NOT how a mortality rate is calculated, which uses all that have contracted the disease as the denominator. See my diagram below:

The outside of Wuhan mortality, where there was wider testing of most that had contracted the disease, was 0.4% based on a report published by the Chinese CDC (7). Mortality on the Princess Cruise outside Japan (the only place so far where you can be sure that you tested all exposed in a closed environment), was 0.85% and only those over 70 died (8). In South Korea, which has tested more than 100,000 people,  the case fatality rate is 0.65% (18). Germany has announced that it’s mortality rate is 0.2% (20). So what’s the real mortality rate? Under 1%. 

The mortality rate for influenza varies by type and immunization effectiveness, but mortality among those 75 years and older is much higher than for the young and is over 1% (9). So we have mortality rates that are pretty close here. Hence, Sanjay Gupta wasn’t reporting accurate information.

The statement that in the elderly the coronavirus is about as deadly as the flu is more accurate. You could also say that it’s harder to treat than the flu and that more middle-aged people need intensive care and that these needs can quickly overwhelm health systems. However, Sanjay should know that the 2-3% number he threw out is likely not accurate and the reasons why it’s likely inflated. 

At the same time, to get the better fatality rates of 0.2-0.65% for COVID-19 that have been reported by other countries, we need to avoid overloading our health systems. That means widespread testing in the US by the end of this week. Here are some media outlets I would like to congratulate as they have actually reported on the evolving science rather than hype:

  • Coronavirus is aerosolized and the flu is not, hence the spread of this disease is much more than the flu.

This is nonsense. The flu virus is also aerosolized which is the primary way it’s spread (1).

  • Coronavirus survives MUCH longer on surfaces than the flu virus, which is up to 9 days on plastic!

This rumor was started by the Washington Post and is also not accurate as written (10).

First, for comparison, the flu virus survives on hard surfaces for about 9 hours and several hours in fluid droplets (aerosols) in the air, with low temperatures increasing the survival of the virus in these droplets (2). Many respiratory viruses die off as the temperature goes up. This is why the flu season is in the winter.

At this point, according to the CDC, there is no evidence that Coronavirus is spread by surface contact (3). The Washington Post article was based on a statement in the conclusion of a research study that found that on most surfaces, other coronaviruses (NOT the SARS-CoV-2 virus that causes COVID-19) survived various lengths of time from hours to days (11). The study that reported that a coronavirus could survive for 9 days on plastic really didn’t say that exactly (5). While that research showed that a different coronavirus survived for 9 days on plastic, by 48 hours the viral load was 10,000 times less! So “survives” is a relative term. In fact, another study included in the same review paper showed a similar coronavirus only practically survived for 2-3 days on plastic, which fits with the fact that the viral load is falling steeply after that time (4).

So how “spreadable” is this virus? The data from the Princess Cruise (Japan), a closed environment where you have almost 4,000 people that live in one space for 2 weeks and infected people touch all sorts of shared surfaces, shows that only about 20% of the people on the ship were positive (8). Given that this one spreads through water droplets from coughing and cruise ships are known to spread respiratory viruses, that spread is pretty typical for the average flu or cold virus.

On the other side of that argument is a new study out of China which has not been peer-reviewed yet (19). This suggests that the coronavirus is more contagious than the flu. It will be interesting to see how this paper fares in the stringent peer-review process. However, it’s critical to look at data from both sides of this argument.

  • The coronavirus will ramp up in the US over the next few months and by summer we will become China, a country on lockdown with millions of cases and our health system will crash.

Blogger Liz Specht gets a raspberry for getting this one out there. She reported that by May we would have some 5.4 million cases in the U.S. using her pandemic math. The problem is that Liz isn’t a physician, so she seems to have missed this graph put out by the CDC (12):

The peak months of U.S. viral flu transmission (which this virus will follow as well as it’s primary spread is aerosolization through coughing) are December through March. This is because the survival of viruses in water droplets falls off the map when the temps heat up. Note that in the 36 years graphed here (1982-2018) we have never had a flu peak in April or May. The graph for other viruses looks similar.

Hence, while the spread of the virus may well be somewhat contained by testing and quarantine which is unprecedented in the US at this scale, if this coronavirus is like the many others we know about, mother nature will likely be the rate-limiting step in the U.S. pandemic math since warmer weather reduces viral spread.

  • Forget about China, the real disaster is Italy!

It’s hard to get much data on Italy at this point. I’ve tried translating press releases put out by the Italian Health Ministry, but they don’t have all that much information. We do know that Italy as of this writing has 9,172 coronavirus cases and has had 463 deaths. So while it’s true that the numbers look awful and their health system is seriously overtaxed (the reports are that they are running low on critical ventilators), an interesting bit of information was reported by the BBC. The Italian health ministry says that the average age of death for Coronavirus is 81.4 years (6). Why is that number VERY important? It means that the data out of Italy so far is following the information we have from the Princess Cruise ship. The mortality is clustering around the very old, which is the same for the flu (13).

However, Italy is a great example for the US not to follow. It took measures too late and in return had massive community spread of the disease. Hence, it’s health systems are overloaded and that drives fatalities up.

  • If you have cold symptoms, you probably have the coronavirus!

I heard this one on a local radio station. The main symptoms of COVID-19 are not the sniffles or a runny nose or sneezing. The main symptoms are a fever and a dry cough with or without shortness of breath (14).

The coronavirus misinformation machine continues to spin out of control. You can’t turn around without hearing a factoid from usually credible sources that can be easily debunked. So listen to the CDC and get yourself tested if you have symptoms. Observe strict quarantine protocols if you test positive. If you’re sick and unsure, just stay home. In the meantime, wash your hands and take a deep breath!

[Given that the comments sections on prior coronavirus posts were not constructive, they will be suspended for this post]. 

_______________________________

References:

(1) Tellier R. Review of aerosol transmission of influenza A virus. Emerg Infect Dis. 2006;12(11):1657–1662. doi: 10.3201/eid1211.060426

(2) Greatorex JS, Digard P, Curran MD, Moynihan R, Wensley H, Wreghitt T, et al. (2011) Survival of Influenza A(H1N1) on Materials Found in Households: Implications for Infection Control. PLoS ONE 6(11): e27932. https://doi.org/10.1371/journal.pone.0027932

(3) Centers for Disease Control. Environmental Cleaning and Disinfection Recommendations: Interim Recommendations for US Households with Suspected/Confirmed Coronavirus Disease 2019. https://www.cdc.gov/coronavirus/2019-ncov/community/home/cleaning-disinfection.html. Accessed 3/9/20

(4) Duan SM, Zhao XS, Wen RF, Huang JJ, Pi GH, Zhang SX, Han J, Bi SL, Ruan L, Dong XP; SARS Research Team. Stability of SARS coronavirus in human specimens and environment and its sensitivity to heating and UV irradiation. Biomed Environ Sci. 2003 Sep;16(3):246-55. https://www.ncbi.nlm.nih.gov/pubmed/14631830

(5) Rabenau, H.F., Cinatl, J., Morgenstern, B. et al. Stability and inactivation of SARS coronavirus. Med Microbiol Immunol 194, 1–6 (2005). https://doi.org/10.1007/s00430-004-0219-0

(6) BBC News. Coronavirus: Italy in ‘massive shock therapy’ pledge to offset virus impact. https://www.bbc.com/news/world-europe-51799956 Accessed 3/9/20.

(7) Chinese Center for Disease Control and Prevention CCDC Weekly. The Epidemiological Characteristics of an Outbreak of 2019 Novel
Coronavirus Diseases (COVID-19) — China, 2020. Vol. 2. No. 8. http://weekly.chinacdc.cn/fileCCDCW/journal/article/ccdcw/2020/8/PDF/COVID-19.pdf

(8) Faust J. COVID-19 Isn’t As Deadly As We Think. Slate. https://slate.com/technology/2020/03/coronavirus-mortality-rate-lower-than-we-think.html Accessed 3/6/20.

(9) Chung, J., Hsu, C., Chen, J. et al. Geriatric influenza death (GID) score: a new tool for predicting mortality in older people with influenza in the emergency department. Sci Rep 8, 9312 (2018). https://doi.org/10.1038/s41598-018-27694-6

(10) Washington Post Staff. Everyday Objects and the Coronavirus. Mar. 6th, 2020. https://www.washingtonpost.com/graphics/business/2020/03/06/amp-stories/surfaces-we-touch-every-day-may-harbor-coronavirus/ Accessed 3/9/20

(11) Kampf, G. et al. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. Journal of Hospital Infection, Volume 104, Issue 3, 246 – 251. https://www.journalofhospitalinfection.com/article/S0195-6701(20)30046-3/pdf

(12) Centers for Disease Control. The Flu Season. https://www.cdc.gov/flu/about/season/flu-season.htm Accessed 3/8/20

(13) Czaja CA, Miller LA, Alden N, et al. Herlihy, Age-Related Differences in Hospitalization Rates, Clinical Presentation, and Outcomes Among Older Adults Hospitalized With Influenza—U.S. Influenza Hospitalization Surveillance Network (FluSurv-NET), Open Forum Infectious Diseases, Volume 6, Issue 7, July 2019, ofz225, https://doi.org/10.1093/ofid/ofz225

(14) The Centers for Disease Control. Coronavirus Disease 2019 (COVID-19)-Symptoms. https://www.cdc.gov/coronavirus/2019-ncov/about/symptoms.html Accessed 3/10/20

(15) Iuliano AD, Roguski KM, Chang HH, et al. Estimates of global seasonal influenza-associated respiratory mortality: a modelling study [published correction appears in Lancet. 2018 Jan 19;:]. Lancet. 2018;391(10127):1285–1300. doi: 10.1016/S0140-6736(17)33293-2

(16) Centers for Disease Control. Weekly U.S. Influenza Surveillance Report https://www.cdc.gov/flu/weekly/index.htm Accessed 3/8/20

(17) American Heart Association. Heart Disease and Stroke Statistics-2019 At-a-Glance. https://healthmetrics.heart.org/wp-content/uploads/2019/02/At-A-Glance-Heart-Disease-and-Stroke-Statistics-%E2%80%93-2019.pdf Accessed 3/10/20

(18) Kolate G. Coronavirus Is Very Different From the Spanish Flu of 1918. Here’s How. The New York Times. https://www.nytimes.com/2020/03/09/science/coronavirus-is-very-different-from-the-spanish-flu-of-1918-heres-how.html Accessed 3/10/20

(19) Sanche S, et al. The Novel Coronavirus, 2019-nCoV, is Highly Contagious and More Infectious Than Initially Estimated. medRxiv Preprint Server. doi: https://doi.org/10.1101/2020.02.07.20021154 Accessed 3/11/20

(20) Der Tagespiegle. So leben die Menschen in der „roten Zone“. https://www.tagesspiegel.de/wissen/italien-kaempft-gegen-coronavirus-so-leben-die-menschen-in-der-roten-zone/25621354.html. Accessed 3/12/20.

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11 thoughts on “Coronavirus Myths Debunked-Episode 2

  1. Michael Knapp, Ph.D.

    Thank you very much for this very clearly presented information. It was very helpful in quelling the panic I was starting to feel.

  2. Travis Lawyer

    Good Stuff. FYI, I don’t know when Gupta asked that question. But he has consistently said on CNN that that 2% figure will get lower as the denominator increases. He has consistently warned of not panicking and has written OpEds with the words “Don’t Panic” in them. At the time, and maybe still now , there are health organizations using a whopping 3.5% figure that is wrong.

    I don’t get a sense of panic at all from CNN. From wathcing them is where I have corrected people by saying it is more like .2% fatality rate. They do bring up lack of testing a lot. It has gotten annoying to me because I didn’t think all people who show signe need to get tested, and I think some health pros have agreed. But it appears that the vast majority of pro’s, including you, think testing everyone with symptoms is important, so I am probably wrong there.

  3. Dr Steve Lissau

    Great Review of Corona….I think the videos of Chinese health workers dressed in spacesuit like protective gear added fuel to the fire. I’ve also been told that the CDC has recommended that corticosteroids not be used to treat these patients for fear of depressing immunity…in my opinion this is nonsense since steroids are lifesaving in treating most respiratory illnesses. Now… how do we calm down this panic?

  4. World B Free

    You lost me at 20% of 4000 is 8

    1. Chris Centeno, MD Post author

      (8) is a citation number.

  5. Derede Arthur

    Here is updated information on how this actual virus (SARS-CoV-2) lives on surfaces — a peer -reviewed study in the New England Journal of Medicine. Link can be found here: https://www.npr.org/sections/health-shots/2020/03/14/811609026/the-new-coronavirus-can-live-on-surfaces-for-2-3-days-heres-how-to-clean-them?utm_source=npr_newsletter&utm_medium=email&utm_content=20200315&utm_term=4460660&utm_campaign=best-of-npr&utm_id=16993633&orgid=15

    Bottom line, says one of the authors, is that “this virus has the capability of remaining viable for days” on a variety of surfaces. Of course the viral load declines with time and UV exposure, and one doesn’t get sick just because one has been exposed to a “little” virus (there has to be enough to overwhelm our immune system)…but it’s something to keep in mind. Wiping down surfaces one touches (CDC recommends a very dilute bleach solution) and washing hands frequently with soap and water or a 60%+ alcohol based disinfectant is key.

    1. Chris Centeno, MD Post author

      Yes, all of the information says 2-3 days on plastic with declining viral loads as you mention. So it’s a good idea to be careful and wash your hands frequently and wipe surfaces as recommended, but the Washington Post was wrong to print that SARS-CoV-2 survives 9 days on plastic. The average person would read that your credit cards will be contaminated for 9 days and able to get you sick if someone else touches them who happens to have COVID-19.

  6. Wolfgang Gröschel

    Dear Mr. Centeneo,
    I’m not a medical doctor. But I do try to interpret the Corona numbers.
    In China there is a big difference between Wuhan (Hubei) and the rest of the country in terms of deaths and serious diseases.
    3099 deaths in Hubei and 218 deaths in the rest of China.
    This can only be explained by different virus types.
    Could it be that the corona test for SARS-CoV-2 is also positive for typical cold viruses?
    It would be helpful to compare the total number of people suffering from or dying of viral lung diseases with previous periods. The corona test should not be included in these figures.

    Similar to SARS, medical personnel without protective equipment are at high risk.
    The 33-year-old Li Wenliang died on 7 February 2020. I have the following message from Italy:
    “At Pope John XXIII Hospital, where doctors and rescue workers are dedicated to corona patients, everyone must also be able to cope with setbacks and sad news. A 47-year-old paramedic from the “118” in Italy, who had been active and in the front line since the outbreak of the virus, was infected – the family man and lifesaver died within a week – no previous illnesses are known.”

    Perhaps you could take up these questions sometime?

    With kind regards
    Wolfgang Gröschel (Jena/Germany)

    1. Chris Centeno, MD Post author

      There are two virus types, one likely more virulent than the other. So that’s part of the difference. In addition, some of this is due to the lack of 100% testing of all positives with the disease. Some also due to trying to find “excess deaths” which rarely happens this early in an outbreak. Finally, the availability of ICU care and ventilators is a big issue. In Wuhan they were in crisis triage mode versus outside of Wuhan. Meaning when your medical system gets overwhelmed your deaths go up.

  7. Shirley Viall

    Thank you Dr. Centeno, the interview with Dan Bongino was very informative. Also your excellent analysis and reporting of the data is exceedingly helpful. We subscribe to your blogs and have explored clinic locations in our area. In the current world of “confused healthcare” it’s great to have your wisdom and clarity available.

    S. Viall

  8. AZ State Rep Bob Thorpe

    Thank you Doctor. Really terrific Info and service to our public. I shared you Bongino interview and this link widely, trying to reduce panic in AZ. Warmest regards, State Representative Bob Thorpe

Chris Centeno, MD

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Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications.
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