As those of you following the COVID-19 story in Real Answers are aware, the emergence of this new virus and its new infection has led to an evolving situation, in which every week is a bit different, revealing more trends and properties of the infection and the countries it lands in.

A quick reminder on terms.

Coronavirus is a name for a species of several viruses, all of which have spiky-shaped proteins on their surface, creating a halo, or crown, or corona.

The name of this particular coronavirus we are talking about is SARS-CoV-2

The disease that this virus causes is called COVID-19.

You may also remember that the two chief characteristics of any infection are:

1. How easily does it spread?
2. How severe is the illness?

Spreadability

Since last week, COVID-19 has continued to show it is contagious, with numbers of known cases exceeding 100,000, and numbers of known deaths surpassing 4,000.

Maps of where the virus are show a wide swath of infection across the Northern Hemisphere, across Asia, across Europe, across the US and Canada, with areas popping up in North Africa and across South America.

The one area where the spread of the virus seems to be slowing is China, both mainland China and Hong Kong, and Singapore.

An earlier post outlined a possible reason- an efficient, high level of identifying infected people and isolating them effectively.

The result?  A 99% drop in the rate of new infections with hundreds of thousands of people from being infected.

This experience suggests, we will see if the spread in China has been nearly eliminated, that nations can act to actual substantially change the spreadability of this disease, one of the two main characteristics of an infectious disease.

Sadly, we cannot report that our own nation, our America, has found a path to reduce the spreadability of this coronavirus.   Instead we have seen the number of infections in the US double, about 250 prior to the weekend, and now over 600.

The two most distressing aspects of the lack of ability of our nation to change the spreadability of this disease are:

1. Failure to put mass screening available across the country
2. Failure to establish actual places for those found to be infected.

What are the implications?

First, this means even today we have no idea how many people have COVID-19.  The current number is 624, but some estimate the real number is around 20,000.  No one knows, but there is confidence the number is much, much higher than 624.   When the real number is revealed, it will be a real shock, and could lead to school closures, business closures, even more cancelled trips.

Second, not knowing who is infected forces the nation to not be able to reduce the spread.  Unknown cases spread far more than known, isolated cases.

Third, testing does not establish end of spread, it just opens the door to that being done.  Once we know who is infected then they can be isolated, the only step that reduces the actual spread.  And to the best of my knowledge, there are not enough isolation spaces to have people wait out their infection risk period instead positive people are sent home where they can continue the spread, a sad state of affairs given that the Chinese have found 75-50% of the spreadability of the virus is through the home.  This is why China leans heavily on isolation spaces, to stop spread in the home.

The last point to be made now is that this virus has spread to where we live, Cuyahoga County.  What we know is that 3 people who live in this, Cleveland’s county, have been diagnosed with having COVID-19.  Keeping mind that our nation has failed to adequately test to see who has this infection, it has left many to be sure that many cases are here in Ohio.  This means these 3 cases are very likely not really the first COVID-19 infections in Ohio, just the first three cases now known.   This specific situation dramatizes how testing is not enough.  For here we have 3 people who are now known to be infected, each of whom of course likely has been in contact with a number of other people who currently are feeling.

Where do the 3 people and their contacts go today?  There are no isolation facilities to go to.  If they are well enough they will go home where others who live at home may be in contact, and if too ill, will go to a hospital that may not be set up yet to provide effective isolation.

Severity

The update on severity does not include many significant changes from last week.  COVID-19 remains a disease that causes mostly mild disease that can death.  The risk of death remains highly related to age, with people less than 30 years old seeing mortality rates that are far less than 1%, at the 0.2% level.  These risks of the infection causing death rise rapidly when looking at ages over 50 and 60 years of age.  For the older members of our community, illnesses more common in the elderly such as heart disease, cancer and Type II diabetes, as well as emphysema also increase the risk of the worst outcome.

An Alternative to Purell

Reports are common that so many stores, even Amazon, is out of hand sanitizer.

Here is one piece of good news: there is a great alternative to hand sanitizers, that works just as well, and there are no shortages on it:  Soap.

Containment v. Mitigation

These are technical terms, terms of the art of public health, which are being used quite a bit.  Here is what they mean:

• Containment – Containment is a strategy of keeping an illness from spreading, with the ultimate goal of snuffing it out all together.  Not many illnesses can successfully be contained.  SARS is an exception, it was in fact contained and snuffed out years ago.   Ebola is not very contagious and can be contained outbreak by outbreak, but has not yet been fully eradicated.  It was hoped when COVID-19 first appeared that we might be able to contain the spread.  In the US our first strategy was to think we could contain it in this nation by cutting off people infected from entering the nation, an idea that never had much science to think it would work, and clearly it has not.  At this time, essentially anyone studying COVID-19 realizes that it is so far spread across the world and across the US that containment is a useless hope, at least until a very effective vaccine or drug is developed.
• Mitigation – Mitigation is a strategy of limiting the damage that will occur in an illness that cannot be contained.  Mitigation can often work.  In 1918-1919 two cities responded to the Spanish flu- the most deadly 1 year epidemic on record.  Philadelphia did nothing to mitigate the impact of the spread of this virus and suffered massive deaths.  At the same time St. Louis took steps to slow, not stop, the spread, including the now familiar closing of public events, reducing gatherings, closing programs, and saw only minimal numbers of deaths.   Mitigation is the strategy the world has at its hands right now to reduce the harm from COVID-19.  The nation with the greatest success in mitigation, so far, is China as noted in last week’s updates and discussed here today.

Approaches to the Epidemic at Advanced Pediatrics

Our office is pursuing a deep look at what will help the most.  Discussions are engaged within the office, and in contact with leading local medical centers, and national experts and resources.

We hope to have a set of policies to share with families in the coming days.

BOTTOM LINES

1. The COVID-19 illness has clearly gone beyond appearing in a few spots and become a disease with proven ability to spread across nations and continents, around the world.
2. The spread of the virus has not achieved the level of disease where it is nearly everywhere, in every city and region in nearly every country, as is seen in massive epidemics such as the annual winter influenza epidemics, but it continues to spread as if it will be.
3. There are indications that the spreadability of COVID-19 can be decreased, but such successes appear to require knowing who is infected (adequate testing) and a place to isolate those found infected (adequate facilities).   Some nations have achieved this, such as China, Hong Kong, and Singapore.  Time will tell if their success is durable and real.
4. Sadly our nation has achieved neither adequate testing or adequate facilities yet.  Last week we were told 1 million tests would be in place by late last week and early this week, but now we know this did not occur, and it remains unclear when it will.
5. As hand sanitizers run out, good news, soap is readily at hand, and works just as well.
6. And, it remains the case that this virus remains a new virus, and its ultimate path remains uncertain- how long will it spread, will it severity lessen or not, so all need to stay tuned.

Let us hope our nation accepts that a virus spreading around the world is spreading here, succeeds in making sure testing is widely and easily available, and provides the facilities necessary to help control spread from identified cases.

To your health,
Dr Arthur Lavin