The Numbers as of March 3, 2020

In the World

• Total number of known cases:  94,244
• Total number of known deaths:  3,220

• Total number of known countries: 77 in all populated continents.  The spread is quite remarkable across Asia and Europe.  The spread in the US is actually unknown given that we have tested only a few hundred people.

In the US

• Total number of known cases:  60
• Total number of known deaths:  9
• Total number of known states: 12
  • All 3 West coast states have cases
  • 6 of the remaining 12 states are on the East coast
  • The 3 closest states to Ohio, which still has no reported cases, are Wisconsin, Michigan, and New York

The spread in the US is actually unknown given that we have tested only a few hundred people as noted above.  It is widely anticipated that starting next week when we go from 500 to 1 million tests and beyond that our numbers will go up considerably.

Mortality Rate

Just today, the World Health Organization released an increase in the estimate of the chance of dying from this infection, formally known as the mortality rate.

This rate had been estimated to be 2 for at least a month or so, if that would be true, then the chance of dying from a coronavirus infection would be 1:50 across all humanity.  The risk is much lower for children, and higher for the elderly and ill.

But as of today, the mortality rate estimate (and it remains an estimate that could change) has been raised to 3.4, which if it is sustained, would mean the chance of dying from COVID-19 rises to 1:30 across all humanity.  It remains the case that children experience far milder disease, and the mortality concentrates in older adults and those with serious illnesses.

Names

It always helps to clarify names.

Name of the Virus

The official name of the new coronavirus, which first appeared just 2-3 months ago, in Wuhan, China is SARS-CoV-2.

To understand this name, let’s look at each part:

• SARS stands for Severe Acute Respiratory Syndrome.  You may think of the illness SARS, which appeared in China from 2002-2004, no known transmissions of this virus since.  That SARS virus was also a coronavirus, with a shocking 10% mortality rate (this round has a current mortality rate of 2%).  But this new coronavirus, the one in the news, is not SARS, but like the SARS virus, it causes mainly respiratory troubles.
• CoV stands CoronaVirus, the species this virus now spreading is part of.   Keep in mind corona means crown and if you look at any coronavirus under a high powered microscope, it shows a big number of protein spikes, which are the sensors that allow the virus to “break” the combination of each cell to break into the cell, and infect it.
• 2 indicates this is the second coronavirus that causes severe acute respiratory syndrome, which is how it makes people very ill and even die.

Name of the Illness

Now, the name of the virus is SARS-CoV-2, but the name of the illness it causes is COVID-19.

• The COV stands for COrona Virus.  The D stands for disease.  The 19 stands for 2019, when it first infected humanity.

To summarize, the new virus on the scene is called the SARS-CoV-2 virus, and the illness it causes by infecting humans is COVID-19.  The slang term for the virus and the illness is Coronavirus.  It is slang because technically, the word coronavirus refers to many viruses that cause many illnesses in humans.

As with any infectious disease, the two dimensions that always define the real chance of harm remain unchanged with COVID-19:

1. Spreadability- how many people will the SARS-CoV-2 virus actually infect?
2. Severity-  How sick does this illness make you, including what percentage will actually die?

Here is an update on these two questions as of March 3, 2020:

SPREADABILITY

Recent trends reinforce the sense that the SARS-CoV-2 virus is spreading.  We still do not really know how many people will actually come down with the illness it causes, COVID-2.  We are fairly sure that number will grow, but how much?

As we wait to see actual numbers to answer this important question, here are some basics to help you understand the numbers, and the trends

First, A Word on Chain Reactions

A key property of a virus is how well it spreads, it’s one of the two main questions that define the level of danger any germ presents, including SARS-Cov-2, the cause of COVID-19.

To better understand the issue of how a virus spreads, it might be helpful to consider a chain reaction.  Chain reactions occur when one event spawns more than one copy of that event.

One of the first uses of the phrase chain event occurred with the discoveries of nuclear energy.  The basic idea was that if enough radioactive material piled together, one split atom would split, they would each split two, so one would lead to 2, then 4, then 8, then 16, then 32 split atoms.  Every step forward in that sequence would simply double the last number.

In this example, taking one event and doubling each time, leads to only 32 events after 5 doublings.  Going from one event to 32 does not sound like much.  But double the number one 10 times, and you go from one event to 1,024 events.  Double the number just 20 times and you get about 1 million events from just one.

The point is that chain reactions can start increasing numbers of events slowly, but once they get going the numbers truly skyrocket.  This how every major epidemic works, it starts slowly, then more rapidly, and if a major epidemic, really takes off.  We have seen this happen with so many viruses- influenza, rotavirus for stomach flu, enterovirus for hand-foot-mouth, it is a very common pattern.

Life itself is built to have chain reactions with the same numbers as above.  Imagine a single celled bacteria, just one.  By definition, no exceptions, every time it reproduces, it ends with two bacteria when once there was one, every time.  That means its reproduction number is 2.  And many bacteria can divide from just one bacterium to two, in about 20 minutes.

Using the same numbers as above, that means once one bacteria divides, and each of its 2 descendants divide into 2, and that happens 20 times; then, one bacteria will end up being over 1 million bacteria, and that’s in less than seven hours!

Now if life could reproduce, doubling the number of any species, twenty times, and every descendant lived to reproduce, and reproduced every 20 minutes, then that species would go from 1 to a million in less than seven hours.  But life doesn’t work that way.  Why is that?

The main reason is that the world stresses life, so it might slow down dividing, or some descendants won’t live, or some other form of life eats that species.  But no known form of life can sustain doubling its numbers without limit (even humanity).

Chain Reactions and the SARS-CoV-2 (the cause of COVID-19)

Now let’s look at what we know about how this new virus works, how do its chain reactions operate?

Again, the virus is new, so we have no idea how well this virus can sustain a chain reaction.  To spread at all, a virus needs to find a way to move from an infected person, to an uninfected person, infect them, and do the whole thing over again.

We spend a lot of time thinking about how our human intelligence can stop this virus.  We talk about what our government and the other governments of the world can do.  We talk about what science will figure out.  We talk about closing schools, or blocking flights, or washing hands.

But there is a highly intelligent problem-solver that we tend to ignore, who plays a big role, likely the biggest role, in how the COVID-19 illness will spread and harm.  And that problem-solver is the SARS-CoV-2 virus.  It can’t talk or walk, but it can reproduce, spread, and harm, and does these things with tremendous skill and ability.

The better this virus is at spreading, the higher its reproductive rate.  In our discussion of chain reactions above, the reproductive rate chosen to illustrate the idea was 2.0, that is every event spawned 2 events.  In infectious diseases, the reproductive rate is called the Ro.  For the influenza currently spreading around, the Ro is thought to be 1.4, less than 2.

Let’s think about that for a moment.  If a virus spreads with a Ro of 1.4, that means, on average, that if I get an influenza virus infection, I will in fact spread it to an average of 1.4 people.  Let’s say it takes my about 3 days for me to spread my cases, then if I get this infection, 3 days later about 1.4 people will have caught it from me.  Each of these 1.4 people will then spread it to 1.4 others, in 3 days.  That is, every 3 days everyone infected will give it to, an average, of 1.4 others who will get sick.  Imagine this happens, and we wait 30 days, then the move from 1 to 1.4 cases will happen 10 times, and if that happens, my one case of influenza virus will go from just me, to 30 people.

And that really happens, it’s how the flu season happens, one person, in about a month or so, will lead to 30 people being sick with the influenza virus.

Now, how do the numbers look for  SARS-CoV-2?  How many of us will be coming down with COVID-19 from this virus?  The real answer is still that we do not know, and we will talk about why not again very soon here.

But for now, let us take two estimates for the Ro of the  SARS-CoV-2 virus.  Initial estimates placed the Ro for the SARS-CoV-2 virus at 2.0, just like our examples above.  That would make it significantly more contagious than the seasonal flu virus.

Think about it.

If I get sick with the influenza virus, and everyone I pass it along to and gets sick does to in 3 days, then 10 rounds later, which is 30 days later, my one case becomes 30.   But if the SARS-CoV-2 virus has an Ro of 2.0, then in 10 rounds, as we saw above, my one case of COVID-19 becomes 1,024 cases, many more than 30.  Now it will take longer, because the incubation period for SARS-CoV-2 is longer than for influenza virus.  Instead of 3 days per cycle, it is as many as 14 days, but more typically about 6 days.  So 10 rounds, taking me with my one case of COVID-19, will take an average of 60 days to complete, but still instead of yielding 30 cases, my one infection will lead to 1,024 infected people after 10 rounds of catching it.

But that is only if the Ro for SARS-CoV-2 truly is 2.0.  And that we simply do not know, there have not been enough rounds of spread to know that number yet.

One recent study looked at rates of transmission more recently, including the rise of numbers of cases in so many countries.  There estimate of the Ro came in at a range that centers around the number 3.0.   Should SARS-CoV-2 actually sustain an Ro of 3.0, then in our example, my one case of COVID-19 would, in 10 rounds of contagion, over say about 60 days, result in 59,000 cases, again just after 10 rounds of catching it.

As another reminder of context, the seasonal influenza virus has an Ro of about 1.4.  And yet, because it sustains this rate of spread, over a time period spanning about 5 months (typically December-April), it infects about 50 million people just here in the US, and 1 billion people worldwide.

A key point, viruses know how to spread across huge populations and across the surface of the planet.  Given a high enough number of people catching it, and long enough period of time in which it spreads, viruses tend to go everywhere, no matter if you wear masks, wash hands, or stay home.

Now back to the emergence of the illness COVID-19 and its current spreadability

I present that thicket of numbers to make a far simpler point:

It matters tremendously at what rate the illness, COVID-19, actually spreads;  and how well that rate is actually sustained.  Bursts of rapid spread do not matter nearly as much as sustained spread and how long that sustained spread goes on.

As we noted above, nearly all of life reproduces at rates that can cause vast numbers of descendants, but in so many cases, something blocks life from having its numbers truly explode, as a chain reaction might do in a lab, or thought experiment.

The SARS-CoV-2 virus, like all forms of life, seeks a way to reproduce and spread, and is doing a very fine job of it at the moment.

There is the possibility that SARS-CoV-2 will succeed in reproducing at a rapid rate and keep doing so for many months, even years.

There is also the possibility that SARS-CoV-2 will fail to do so.  It seems close to certain that it will spread quite a bit now, but far from certain that the rate of spread will continue at its current brisk pace, or not.  And if it does start to spread at a higher rate, will it keep doing so for a long time?

If it doesn’t the number of cases of COVID-19 will possibly not rise to the millions and millions.

At this point in time it seems more and more likely that this virus, the SARS-CoV-2, will be spreading widely, and more likely that means it may spread like the seasonal flu, which means, essentially everywhere.   We do not know enough to be sure of this, but indicators are pointing to such a spread being more likely.  Again, we still have no idea, even if this happens, how long the infection will continue to linger- a few weeks, a few months, even a year or two, we simply do not know.

Should the illness COVID-19 become a common infection around the world and, like influenza, in essentially every community, like many viruses, such as the common cold and influenza viruses, then travel will at some point no longer be an issue.

Keep in mind, every widespread epidemic goes through at least 3 phases, every time.  Most start somewhere.  Then in the 2nd phase we see areas of infection pop up.  And if it is to happen, a 3rd phase emerges where the virus is causing the illness everywhere.  We have gone through the first 2 phases of COVID-19 illness already.   It started in a particular city in China, Wuhan.  It is currently in the 2nd phase- popping up in various centers, more every day.  Initially S Korea, the cruise ship; then Italy and Iran; now it’s in 77 countires and spreading rapidly, suggesting more and more, that it will achieve the 3rd stage, widespread occurrence essentially everywhere.

Now, in thinking about travel, it makes sense, should this virus appear in only a select number of spots, to not go there.  But think about what happens if this virus does spread like other viruses and ends up here in Cleveland, and every city and village in the world.  Then it really doesn’t matter if you travel.  Just consider the seasonal colds and flus again, they are everywhere, so staying home or traveling has no impact on your chances of catching it.  So considerations of the relevance of travel and other attempts to avoid catching it, will hinge on whether COVID-19 remains an illness only seen in select areas, or goes everywhere.

SEVERITY

This new coronavirus is not alone in causing a range of illness, all viruses, and really, all germs do.

Just think about all the colds you, or your children have had. Some are very mild, some are very bad, many are in-between.  A mild cold might be a sniffle, sneeze, and runny nose for 1-2 days, no fever, and then fine.  A really bad cold would be high fever, very miserable, constant sneezing for 4-6 days and a horrible cough for 2-3 weeks.  You are surely familiar with both extremes and all degrees in between.

This new viral illness, COVID-19, is no different in being a respiratory illness with a range of severity.  It clearly causes a full range of colds, or to be more technical, respiratory illnesses, causing inflammation of noses, throats, and lungs, like any cold virus does.  Just like all these colds, COVID-19  can cause very mild illness, in fact it really tends to.

Here are recent figures from WHO on 44,000 cases of COVID-19:

• 81%   have mild illness- meaning mild as noted above, not too sick for not too long
• 14%   have severe illness- as you would expect, this means feeling quite horrible, but not in danger
• 5%     have critical illness- at risk for possible death,(perhaps a little less than half of people who get this ill will not recover).

A very important point here:  children seem to experience significantly milder COVID-19 illness than adults.

Some good news is that it is hard to know how many people walking around, feeling fine, with no symptoms, have an infection with SARS-CoV-2.  These are called asymptomatic cases, since they have no symptoms.   As testing becomes more widely done (see below), we will have a better idea how many are asymptomatic.  Being infected and having no symptoms turns out to be very common in all sorts of infections.  For example, we know that a full 33%, or 1/3, of everyone infected with strep throat at any moment in time, have no symptoms at all.

The percentage of people infected with the SARS-CoV-2 virus who are asymptomatic could dramatically lower the rate of dying from this disease.  For example, let’s just say that it turns out half of everyone infected with the SARS-CoV-2 virus is asymptomatic, then that would cut the mortality rate in half.

Here’s how.  Right now we know that 94,244 people have been diagnosed as having COVID-19, and of those 94,244, 3,220 have died.  That implies that 3.4% with the infection have died.

But, if it turns out that right now that half of all those infected have no symptoms, then the actual number infected with the SARS-CoV-2 is 188,488.  The number of deaths does not change, but if  about half are asymptomatic, then the real chance of this illness leading to death goes down to 1.7%, half the currently stated chance.

A statement from the World Health Organization, however, tells us that the WHO feels that most people who get infected with the SARS-CoV-2 virus are not asymptomatic, that is, they have some symptoms- like runny nose, fever, sore throat and cough.  Their spokesperson actually was quoted on March 3, 2020: “This is a disease that is in the cases and their close contacts. It’s not a hidden enemy lurking behind bushes.”     The WHO simply has not found much evidence for much asymptomatic disease.   If this observation holds up, and again we do not know if it will, then the mortality rate of around 3.4% could possibly remain at that level, at least not diluted by large numbers of people infected not being ill at all.

So, like spreadability, the actual severity of this virus and its disease, COVID-19, is not yet established.  The initial estimates are noted above, the vast majority of those infected do not get very sick, but many do, and at this point it appears that something like 3.4% will actually die, mostly older adults, not so with children at all.

TESTING

We are all quite used to having testing available for so many infections.  Getting tested for strep, influenza, UTI’s are routine events and easy to get done.  But testing for COVID-19 has taken awhile to make routine, mainly because it is a brand new disease.

For new diseases, however, testing is essential to figure out answers to the two key questions posed by any illness, again:

how many people will catch this illness, and how severe will it be overall.  Only by testing and watching can these answers be found.

Unfortunately, testing in the US got off to a failed start.  The CDC took charge of supplying all health facilities with test kits, to ensure the highest quality, but their first lots turned out to be defective, leaving the US with almost no testing ability.  As late as last weekend, the whole nation had only done 500 tests.  What that means is that we are right now blind to our numbers.

Reports may say there are 2 cases in this state, or 10 cases in that state, but that just means a handful of people in that state were tested, and that many were positive.

It is instructive to consider the outbreak in the state of Washington.  In one instance, genetic analysis of the SARS-CoV-2 virus allowed epidemiologists to conclude that the infection present in just 2 people studied indicated that there were about 1,500 active cases in the state of Washington.

This blindness will not last long.  We are told a million testing kits will be released for use next week.  Advanced Pediatrics will be tracking availability of testing kits to ensure we know where the tests can be done if and when we need to know.

THE VIRUS AS A PERSONALITY

It bears repeating before we leave this week’s update, that every form of life has a powerful intelligence, at the very least, it knows how to live and reproduce, or it would not be alive or spread about.  Viruses are an odd form of life, consisting only of a protein coating a bit of genetic material, but they have mastered the art of living by reproducing.

Viruses have practiced this art for much longer than we have.  Humanity has been around for about 200,000 years.  Viruses have leapt from cell to cell for over 3 billion years!

Every form of life experiences viral infections, even single-celled bacteria get such infections.  So viruses have been flying around, spreading, reproducing for billions of years longer than humanity even first appeared.

The point is that we may like to think we can stop a virus, but for most viruses that is simply not true.  The only viruses we have had any impact on are the ones we immunize against, the herpes viruses with use of the drug acyclovir, AIDS virus with its medications, and the SARS virus which is the only virus ever snuffed out by quarantine.

For all viruses without a medication that truly contains it, or an immunization that stops its spread, the virus and its intelligence honed over billions of years, rules.

WHAT CAN BE DONE, WHAT CANNOT BE DONE

This post concludes with a brief few thoughts on some deep realities of viruses, especially viruses that infect the nose, throat and lungs:

1. These viruses spread well on their own, they travel from person to person in the air and have spent billions of years perfecting this craft.
2. As a result of virus ingenuity, human actions to stop the flow of virus (masks, hand washing, isolation, quarantine, staying home from work, curtailing travel), tend to not work very well.
3.  Time will tell if any actions we take, masks etc., will slow the spread of the illness COVID-19.  Early indicators in China suggest that extremely strict quarantine across populations of 50-60 million people might slow the spread, but the emergence of COVID-19 across over 100 countries suggests milder interventions such as hand washing, masks, and isolation, do not have much of an impact.
4. This is not too surprising, imagine trying to stop the spread of colds in a country, it has never been achieved, they spread even against our best efforts.
5. As with so many viruses, there simply is no effective cure for COVID-19.  There are no drugs known to reliably kill the virus or slow its progress.  If very ill, IV fluids and oxygen could help and are worth trying.
6. There are three springs of hope that are still very strong:

• The virus, SARS-CoV-2 may yet peak soon and fade away.  Every week makes this hope seem more unrealistic, but two dimensions of the virus’ behavior may yet help us out- it may slow down the speed of its spread and infect hundreds of thousands rather than hundreds of millions.  Secondly, it may prove to be less deadly over time.
• A medication that either kills, or slows down the potency of this virus may be discovered.  Reports are common that “we are close” to identifying such a medication.  But we should not feel this hope turns real until an actual medication is used in actual people with actual COVID-19, and we see it is BOTH safe and effective.  We have no such medications right now, but we might some day.
• An effective immunization would render the SARS-CoV-2 virus about as worrisome as the polio virus, and COVID-19 would go the way of polio.  And we are pretty good at creating new vaccines, but it is a tricky business.  We might get a good candidate, but it may prove in real world use on real people to either not work very well or cause some serious harm. Again, this is a real hope, we are told on good authority it is unreasonable to see it in use for  at least a year, more likely 18 months, and no one knows of candidate COVID-19 vaccine will work or be safe.

Putting these 6 points together, one could reasonably argue that the real value to anyone being tested for COVID-19 is to help the community guage how the virus spreads and how sick it makes people.  For an individual, knowing you have COVID-19 will likely not slow down its spread, and will certainly not open the door to any specific treatments at this tme, all of which are put into place if you are sick enough to need IV fluid and/or oxygen, no matter which virus makes one sick.

BOTTOM LINES

1. The new disease COVID-19 is very real, and has moved past the initial stages of a very widespread epidemic- going from appearing in its first spot, then to a number of new spots, towards a very widespread occurrence.  Viruses do this all the time, so it would not be strange if this one did too, and looks more like it will than ever before.
2.  A very strong majority of people who get the illness COVID-19 will not get very sick, they will have what looks like a mild cold, that’s it.  This is clearly more likely if you are a child.
3.  If the virus spreads to essentially everywhere, then efforts to stop its spread will no longer make as much sense.  If every city has COVID-19, then flying to another city will not increase your  chance of being exposed, for example.  If we continue to believe COVID-19 is only in select cities, then it continues to make sense to avoid travel there or have them travel to areas free of the disease.  That is the situation today, but each week it appears that we are moving towards it really being essentially everywhere, as viruses tend to do.
4. The current evidence suggests that if you get infected, you do tend to get symptoms, not so many people who get infected have no symptoms.  If this proves true over time, then if you feel fine over the course of the incubation period, you can be very confident you do not have the infection.  This point may change so stay tuned.
5.  Sadly, COVID-19, at least through today, is sustaining a mortality rate, which has now been increased from 2.0% to 3.4%.  Now about one in 30 people who get COVID-19 are dying, up from one in 50 people.  The majority of these tragedies are happening in older adults and people seriously ill before being infected.   Healthy young people have a substantially less risk of such tragedy, thankfully.
6.  As with colds, stomach flus, and other viruses, we have little control on how it spreads who gets it.  There are no drugs known today to stop its spread or cure the infection.  There is no vaccine for COVID-19.  Such measures are being aggressively developed, but we do not have them in hand yet.   Until we do, our power to slow the spread will, realistically speaking, be rather limited.
7.  Testing in the US is on the verge of taking off, we should expect to find that instead of 60 cases, there are many thousands in the US, and instead of 12 states, many more, all consistent with our first Bottom Line above.

We are disappointed this new virus did not sputter, and appears to be succeeding in spreading and causing harm to a small minority of people.  We only hope it fails to continue and that we succeed in finding medications and a vaccine soon.

Here at Advanced Pediatrics we have begun contacting the Ohio Department of Health and intensive discussions within the office to develop policies that will inform, help, and protect all the families in our practice.   We hope that everyone comes through this new virus well.  However the virus goes, we will remain available to help answer questions and provide care and advice.

To your health,
Dr. Arthur Lavin