Coronavirus Update Episode 3: Keep Calm and Carry On…

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In wartime Britain, there were posters all over the place that had a purpose. Keep the public calm in a crisis while motivating them to do certain critical things. However, in this viral crisis of 21st century America, the media seems to be doing just the opposite. While a handful of science journalists are trying to balance the coverage, those stories are getting drowned out right now by those causing abject panic. So today, I’ll update where we are by diving into what we really know, as this problem evolves daily.

This Is NOT the Flu

The SARS-C0v-2 virus which causes COVID-19 is not the influenza virus that causes the flu. First, about half of the people that get the coronavirus (COVID-19 is what the disease is called) merely feel like they have allergies or are a little sick and recover quickly. Another 30% or so gets what seems like the flu and recovers. The big question is what happens to that other 20%? Near as I can tell from looking at the data, most of these end up with a nasty, but manageable viral pneumonia. HOWEVER, likely about 3% of the total infected need intensive care. The problem? No health system is designed to treat 3% of a large number of infected individuals in an ICU. This last stage of the virus impacts the elderly, and health systems, hard. Especially when a good chunk in that category needs to be on a ventilator to have a shot at survival.

However, Some Historical Perspective

As of this morning, we have had 4,638 deaths worldwide due to coronavirus. Again, the seasonal flu kills between 291,000 to 646,000 people worldwide every year (3). The CDC announced earlier this week that the US had 20,000 flu deaths this season with 350,000 hospitalizations (4). In the 2017-18 flu season, 80,000 in the US perished with 900,000 hospitalizations (7). Today, based on annual worldwide stats, 48,219 people will die of cardiac disease (5).

The time we’re in right now reminds me of Britain in World War II. The government needed to both mobilize the public to do certain things and not cause a panic. So thousands of these posters were plastered all over London and the country. However, that’s not really what’s happening now as I see more panic messages in the media than calming ones. We could really use a dose of Winston Churchill’s pragmatism right now.

Kudos to our local Governor, Jared Polis, who has been relaying these “Keep Calm and Carry On” type messages in his press conferences. While I didn’t vote for Jared, he’s doing a good job of both informing and keeping his head. That’s leadership in a crisis.

Community Spread and Closures

This picture is from my local Target. This is the paper goods aisle. The picture speaks for itself.

We have seen unprecedented college, school and event cancellations this week. I would guess that we will see almost all colleges and universities close their campuses by week’s end. This is NOT a coronavirus vulnerable population, but it may reduce community spread. Last night the President canceled all flights from Europe to the US (except the UK) for one month. The World Health Organization (WHO) just declared this virus a Pandemic.

Coronavirus 101

The key points to understand so far are the virulence of this virus and how fast it spreads. If you haven’t been following my posts, this is a key diagram to use in understanding why the fatality rates for coronavirus are wildly inflated at this point:

This diagram is based on CNN’s Dr. Sanjay Gupta’s claims that the fatality rate of the coronavirus is 2-3%, which means that 2-3 out of 100 people who contract COVID-19 will die. I’ll call this “Gupta Math”. The problem is that in order to figure out how many people who contract the disease will die, we need to accurately know the total number of people who contracted the disease. Since about half of those never felt sick enough to prompt a test, the fatality rate is inflated based on using the smaller number of people who felt sick and got tested.

The smarter science types in the media have picked up on this “Gupta Math” and have published these articles:

In addition, we’ve now seen the fatality rate out of South Korea, an industrialized first-world nation that has been using widespread testing and quarantine. It’s 0.65% and they believe that they’ve mostly contained this virus (2). Germany, who has been aggressively testing and quarantining patients is reporting a 0.2% fatality rate (10).

The BEST Data We Have on this Outbreak

You really couldn’t ask for a better natural experiment that tells us how virulent and how fast this virus spreads than the Diamond Princess Cruise. Why? It originated in WUHAN CHINA, the epicenter of this newly declared pandemic. Everyone on that ship was tested for coronavirus and then quarantined for two weeks. Why is that critical? See above.

We know that on the 20th of January, an 80-year old passenger got off the ship in Hong Kong and about a week later he tested positive for the coronavirus. So this cruise ship was out there for approximately a month with at least one and likely several people who had the virus, all living in close quarters. A cruise ship is a “viral spread machine”. A shared air handling system circulates viruses and lots of shared spaces that nobody can avoid distributes anything that can survive on hard surfaces. Hence the same people get exposed over and over again.

When the cruise ship arrived in Japan on Feb. 5th, it was quickly quarantined and the Japanese authorities set about testing everyone on the ship. That was a Godsend for epidemiologists trying to figure out the fatality rate and spread patterns of coronavirus.

The Diamond Princess Cruise by The Numbers

First, what happened on this ship and is happening worldwide is a tragedy. So let’s keep that in perspective as we look at the Diamond Princess Cruise pandemic math:

  • There were 4,061 individuals tested who were exposed (1)
  • 705 tested positive
  • 7 patients died
    • 3 Japanese citizens in their 80’s
    • “An elderly Japanese man”-age unknown
    • British national in his 70’s
    • A 78 year old Australian national
    • Hong-Kong national-age unknown
  • The infection rate of those exposed is 17%
  • The fatality rate (exposed versus deaths) was 1.0%

What does all of that mean? The fact that only 17% contracted COVID-19 on a cruise ship that was out there for a month before being quarantined is NOT impressive. In fact, epidemiologists usually see 20-40% of individuals in a population test positive for the influenza virus during a bad flu pandemic.

Also, pay attention to the 1% fatality rate impacting mostly the elderly. That number had previously been reported as 0.85%. There was a new death recorded so that number has gone up. However, please note that the average age of cruise ship passengers is older by about a decade than the average age of the United States population.

What Else Can Hit the Older Elderly Hard?

Do you see a trend here for who perished? Notice how you don’t see any mention of 20-year-olds, or kids, or middle-aged or even people in their 60’s. Let’s peg the average age of those that perished on the cruise in their early 80’s. In that age range, what else can have a similar fatality rate in the older elderly? The flu.

Even more vulnerable to the flu are the elderly in long-term care facilities. How vulnerable? In one study, 10-20% of the elderly in their late 70’s diagnosed with influenza perished from the disease or secondary complications (6). This is also important for how we look at COVID-19. Why? Older patients are more likely to have more things wrong with them that add to the risk of death. For example, early reports of the first 104 post-mortem exams in Italy show that more than 2/3rds of patients suffered from at least two or more life-threatening pre-existing conditions (11).

So what’s different about the coronavirus? First, depending on the year and whether the flu vaccine works and is used widely and whether older people have antibodies to that bug, being in your 60s or 70s could carry some protection. Why? There is a greater chance that the elderly have antibodies to the bug. In fact, the 1918 pandemic didn’t hit the elderly as hard as it hit young people without antibodies. However, the coronavirus is new, so it’s hitting the older elderly especially hard. For example, the Italian health minister stated a few days ago that the average age of death in Italy due to COVID-19 was 81 years old (8). That same pattern of the oldest elderly getting hit hard also happens with the flu. Those in their 80’s are hit harder due to a weakened immune system because, at that point, even antibodies don’t help.

Why Is This Spreading So Fast in the US?

We likely have thousands of people with Coronavirus walking around this country right now. The vast majority have no idea they have the virus and many have already recovered or are recovering. However, we only began testing for the virus with any significant frequency this past week. Most states are just getting started on creating European and Asian style “drive-up” testing centers now. Hence, most of these “new” cases, aren’t new. So expect the US counts to look like they are exploding for at least another 1-2 weeks. However, much of that is likely catching up on the detection of existing cases.

Good News?

The peak respiratory virus transmission month is February (9). The transmission rate goes down in March as spring begins. Transmission rates go down again in April and again in May. So the US is getting in on the tail end of this pandemic. This fact combined with unprecedented measures to reduce community spread should mean that we’ll be fine. However, let’s all say some prayers for the elderly in Italy, where they are running out of ventilators and ICU space.

My Recommendations

As our Colorado governor said last night, the government can only do so much here, so just like in wartime Britain, we need individuals to their part. Hence:

  • Listen to the direction of the CDC and the authorities
  • Wash your hands frequently for 20 seconds with soap and water
  • Give up handshakes for now
  • Use social distancing where possible (stay 3 feet back)
  • If you’re sick, stay home
  • If you have a dry cough and a fever with or without shortness of breath, see your primary care physician. He or she can decide if you need to be tested.
  • Don’t PANIC

The upshot? This is a bad bug and we should do everything we can to prevent it’s spread. However, most in the media continue to plant the seeds of panic. Don’t panic, do your part in reducing the spread of the disease, and take a deep breath! Stay tuned here for weekly updates as more data comes in.

______________________________________________

References:

(1) Wikipedia. 2020 coronavirus pandemic on cruise ships. https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_on_cruise_ships Accessed 2/11/20

(2) 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

(3) 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

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

(5) 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

(6) Potter J, et al. Influenza Vaccination of Health Care Workers in Long-Term-Care Hospitals Reduces the Mortality of Elderly Patients. The Journal of Infectious Diseases. 1997; 175:1-6 Link here

(7) NBC News. Doctors deliver blunt message about a record 80,000 flu deaths. https://www.nbcnews.com/health/health-news/doctors-speak-bluntly-about-record-80-000-flu-deaths-n914246 Accessed 3/12/20.

(8) 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.

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

(10) The Local de. What explains the low coronavirus death rate in Germany? https://www.thelocal.de/20200310/what-explains-the-low-coronavirus-death-rate-in-germany. Accessed 3/12/20.

(11) 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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Chris Centeno, MD

Regenexx Founder

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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