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Saturday, March 7, 2020

Post #48 Coronavirus COVID-19 Pandemic Update

Well before news of COVID-19 wreaked havoc on our borders, travels, news cycle, and hand sanitizer supplies, influenza was quietly going about its yearly routine business with minimal hubbub from the media.

To put things in perspective, consider that for the 2019-20 flu season, there have been an estimated 20,000 - 52,000 deaths thus far per the Center for Disease Control in the United States alone. That is just one country.

In contrast, there have been approximately 3,600 deaths from COVID-19 worldwide. More deaths are sure to follow, and quite possibly, the final tally may far outstrip that of the seasonal flu.

An unknown enemy is always more frightening than one that is known. With the flu, we know what to expect, we have medications to combat it, and most importantly there is an effective vaccine readily available each winter.

Unfortunately, with COVID-19 there are still a LOT of unknowns. 

But we know substantially more now than we did when this all started and we are learning more each day.

The Case Fatality Rate (CFR) is likely overestimated and will hopefully trend down.

One of the best handles as to the seriousness of a pandemic is to look at the Case Fatality Rate and compare it to other previous pandemics. 

The Case Fatality Rate is simply the ratio of deaths from a certain disease to the total number of people diagnosed with this disease for a certain time period.

As a frame of reference, the 1918 Spanish Flu, one of the worst pandemics of all time, had a CFR of approximately 2.5% to 10% - meaning that about 2.5 to 10 percent of all people who caught the Spanish Flu died. Anything greater than 2.5% would certainly be devastating worldwide.

Conversely, the seasonal flu typically has a CFR of approximately 0.1%, which is still concerning, but as mentioned in the introduction of the blog, the world has learned to take this in stride.

The more data is collected, the more accurate the CFR estimates become. The initial CFR estimates for COVID-19 were in the 2-3% range and recently the World Health Organization released a 3.4% estimate.

Certainly, these estimates are enough to give even the staunchest epidemiologist pause.

But in order to make the best guesstimates of CFR early in the course of a pandemic there must be widespread testing. Lesser testing detects fewer cases, which skews the CFR higher. This was seen with the 2009 H1N1 Influenza Pandemic

Currently, there are two microcosms of the pandemic that can give us the best estimates of the CFR for COVID-19. In both instances, widespread testing of the particular cohort has provided better data and thus a truer estimate of the real CFR.

1. The Diamond Princess cruise ship

The Diamond Princess cruise ship which had approximately 700 lab confirmed cases of COVID-19, has reported 7 deaths to date. This translates to a CFR of 1%. Importantly, it should be noted that all of the deaths occurred in passengers 70 years and older.

2. South Korea

South Korea is currently testing thousands of people a day and thus far 6,088 cases have been detected of which 37 have died. This translates to a CFR of 0.6% for South Korea. This is probably more accurate than the cruise ship figure, as the Korea numbers are more age-demographically balanced, whereas the cruise was populated by predominantly older people.

While a 0.6% CFR is much better than a 3.4% CFR, it is still significantly higher than the seasonal flu's 0.1% CFR. That figure would translate to 6x the number of people dying, if the same number of people who catch the flu annually were to catch COVID-19. 

The hope is that even in South Korea, there are many who have been infected that have NOT been tested, and are thus unaccounted for in the statistics. Accurately capturing their data would certainly bring the CFR percentage even lower. 

The bottom line is that while it is unlikely that the final CFR tally will come in at 3.4%, there is a strong chance that this pandemic is more deadly than the seasonal flu. More testing, better data, and clarity are sure to come.

Thus far, children are not being seriously affected.

A huge encouraging statistic as a pediatrician is that no children under 10 years of age have died from the COVID-19 to date and, for unclear reasons few children are developing severe symptomsThis pattern is similar to what was seen during the outbreaks of SARS and MERS. 

Children are at similar risk as the rest of the population in terms of becoming infected; so it is imperative to consider them as vectors of the virus, especially since they are less symptomatic and thus more ambulatory, and less prone to prudent hygiene habits.

Healthy people 60 years and younger are at much lower risk.

Although there are some fatalities in nearly every age demographic, the vast majority of deaths are occurring in individuals 60 years and older. Further, people who have a severe chronic medical condition affecting their heart, lungs or kidneys are also at greater risk. This follows a similar pattern to influenza and most severe respiratory viruses.

So, if there is a silver lining in any of this, those who are under 60 years of age without significant health problems have an excellent prognosis should they become infected with COVID-19.

But the fact remains that as of the writing of this blog, the CFR is likely higher than the seasonal flu and possibly significantly higher. Intensive Care Units and hospitals in China and in South Korea, particularly near the epicenters of the outbreaks are overwhelmed.

If these two countries are a peek into the future for the rest of the world, this is going to be a long and difficult battle and it will have to start with grassroots efforts. We as a society will need to be vigilant in following the directives of our public health officials and practicing a high level of personal hygiene habits.

The CDC has an excellent list:
  1. Avoid close contact with people who are sick.
  2. Avoid touching your eyes, nose, and mouth.
  3. Stay home when you are sick.
  4. Cover your cough or sneeze with a tissue, then throw the tissue in the trash.
  5. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe.
  6. Facemasks: CDC does NOT recommend that people who are well wear a facemask. Those who are showing symptoms should wear them to prevent the spread of disease. Health care workers and caregivers should also wear them when taking care of those who are infected.
  7. Wash your hands often with soap and water for at least 20 seconds. If soap and water are not available use an alcohol-based hand sanitizer with at least 60% alcohol.

For the sake of those who are most vulnerable, we must band together to slow the spread of this disease. By slowing transmission, hopefully hospitals will not be overwhelmed with a tsunami of cases leading to a likely depletion of important resources such as ICU beds, ventilators, and healthcare workers. 

Additionally, there is hope that by this time next year a vaccine will be available. As more research is published and experience gained, the medical community will develop a better understanding of which combination of antiviral medications and treatments work best.

And if COVID-19 mimics other respiratory viruses, the upcoming warmer weather may provide a temporary reprieve, giving the world a chance to catch its collective breath before the battle begins anew in the upcoming fall and winter. 

Based on current epidemiological data, it is likely that the COVID-19 virus is not going away anytime soon. But the human race is strong and resourceful and we have more weapons at our fingertips than ever before. 

Now, more than ever, for the sake of the elderly and those with fragile health, it is imperative that we do the small things like washing our hands and staying at home when sick. 

When we stand together, there is nothing too strong or too deadly that the human spirit cannot overcome.


Unknown said...

Thanks for this very informative blog.
Is there any CFR information for other countries such as China, Japan, Italy, Iran, etc?

MiriamG said...

Thank you so much for publishing this!

Peter Jung said...

I think the CFR for other countries is being reported as much higher than the 0.6% South Korea number as the testing in other countries has been limited but growing. The 3.4% WHO number quoted in my blog is derived from early China/Italy/Iran numbers I believe. We should have a better handle on the true CFR of COVID-19 as more widespread testing becomes available/recorded.

Elena Denis said...

Thank you for this article. It is the best one I have read so far- and I have been reading a lot about it from many different sources. It is factual, logical, and such a good reality check!
Elena Denis

Elena Denis said...

Thank you for this article! An outstanding reality check!

Michelle Rego said...

Thank you for taking the time to get this information together Dr. Jung! Always helps to go over facts rather than give into panic. I found this extremely helpful!!! Going to pass it onto some of my friends who are also concerned about their kids:)

Unknown said...

Thank you for this as it helped articulate and address many of our concerns.
You mentioned prognosis is good for those below 60. Is there a resource that explains what to expect if contracted with the virus and duration of illness, including best way to treat at home. People in Italy are highlighting how the medical capacity is being overwhelmed because everyone is going to the hospital.
Also curious if your office will see a decline in general sick visits now that many are being sensitive to good hygiene practices.
Thank you again and please continue to keep us informed with your perspective.

Peter Jung said...

There are several articles out there that describe what is happening to the body with Coronavirus. This one is excellent:

Italy was slow to respond with public health measures. If the USA follows Singapore and Korea and acts quickly, it can help stave off the onslaught of cases allowing for the hospitals to operate effectively and handle the load.

Our sick visits the last few weeks have been normal/high, mostly due to seasonal flu. This past week, I did feel the acuity of the flu letting up some, either secondary to seasonality or hand washing or because many have already caught the flu and are now protected.

Thanks for your support!