The hospital has been busy these last few months. Flu season came early this year, beginning with predominantly Influenza A, and continues even still with a second wave of a different strain, Influenza B. Despite my flu shot, I think I got both strains this year as I was ill twice over the holiday season. Not too surprising really, the flu shot is only about 40% effective (but better than nothing) and the ER has been packed tightly with sneezing, coughing, feverish patients.
I was comforting myself with the illusion that I now had double flu immunity when a report came of yet another new viral respiratory illness out of China, the novel Coronavirus (2019-nCoV).
There are many strains of Corona virus (CoV) and most are benign. Corona viruses are one of the leading causes of the common cold, for example. But other strains of Corona virus can be more deadly, such as the SARS CoV with a mortality of 10%, or even worse, the MERS CoV with a mortality of 30%. SARS CoV has died out but MERS CoVis still circulating at very low levels in Saudi Arabia. (MERS is the Middle Eastern Respiratory Syndrome)
Day by day, the reports of Corona virus news from China have become more and more concerning. No one knows how infectious this new illness is, or how deadly, but we do have some preliminary clues.
The first clue is the extraordinary lengths the Chinese government is publicly taking to try to contain the spread of the virus. They have pledged to build a 1,000-bed hospital in Wuhan, the center of the outbreak, in an astonishing 10 days. It is now almost finished. Another 1,300-bed hospital is scheduled to be built in the next month. This is the equivalent of building three U.Va. hospitals in a month. Impressive, but also concerning.
The Chinese have also quarantined 56 million people in Hubei province and shut down all public transportation in and out of 15 cities in the province. Again, an impressive display of authoritarian government might, but also concerning given that the Chinese government is notoriously secretive when it comes to public health threats. If they are signaling this much worry, that is unusual, and it worries me.
In service to this habitual government secrecy, the first Chinese physicians to report the novel viral outbreak were investigated by the police and issued warnings to stop spreading rumors or risk imprisonment. This is pretty typical. This was in early December 2019. It wasn’t until January 20 that Chinese president Xi announced the outbreak to the nation. By then it was too late. The disease and the death rate had exploded.
Fueled by this secrecy, and coinciding with the Chinese New Year’s celebration with its attendant mass travel (by custom most Chinese return to their hometowns for the festivities) the virus escaped the confines of the city of Wuhan where it began and went worldwide. You see the Chinese New Year’s annual travel is the largest mass migration event on the planet. Three billion people a year travel for it, 79 million of them by airplane.
The next clue we have is the speed at which 2019-nCoV has been spreading. From 50 cases in China in early December there are now an estimated 100,000 cases worldwide. This seems to indicate that 2019nCoV is slightly more infectious than the common cold and influenza. It is very likely to become a pandemic (an epidemic on two or more continents).
What we don’t know is the lethality of this new virus. Early reports are lurid with high rates of fatality but are certainly inaccurate as China does not have the capability of screening or treating all of those with symptoms. While we know fairly accurately how many people have died (360 as of this writing), what we don’t know is how many total have been infected. China has reported 17,000 cases of 2019nCoV to date. Accepting China’s numbers as accurate would indicate a fatality rate of 2%, which is quite high. Influenza’s fatality rate is 0.1 %.
But China’s numbers are certainly inaccurate and the fatality rate by my estimate is closer to that of influenza. This is still alarming as 35,000 Americans die of influenza each year and this virus has the potential to infect even more people than influenza.
So what should we do? There is no vaccine and no practical anti 2019nCoV medicine. We are going to have to look to the past for answers to this one.
There were three influenza A pandemics in the last century, with the 1918 pandemic being the most deadly. Labeled the Spanish flu, it actually originated in the U.S., almost certainly as a mutation from an avian source. The mortality was shocking, with estimates as high as 50 to 100 million people killed worldwide. There was no vaccine and no antivirals, but there were effective non-pharmaceutical interventions. A group of medical historians and Center for Disease Control epidemiologists studied the public health records from 100 years ago and reported some interesting findings in the August 2007 issue of JAMA. They looked at 43 U.S. cities and their responses to the 1918 flu pandemic. Cities that cancelled school and public gatherings early in the pandemic and kept them cancelled for long periods of time had half the mortality of cities that waited till the flu was already upon them wholesale. Staying home saved lives. While China’s 56-million-person quarantine is drastic, it is well supported by the literature. Had they cancelled New Year’s travel sooner, though, this virus might have never spread this far this fast.
Not much has changed since 1918 in our vulnerability to pan-flu. A sudden mutation would preclude a vaccine in the first several months of attack and antivirals will be in short supply, if effective at all. If 2019nCoV comes to the U.S. in large numbers, we will have to go old school, pun intended, and cancel school. We call it “social distancing” now, and it is intended to reduce what is known as social density. Preschools are the most crowded social environments with 35 square feet per student, followed by elementary schools at 49 square feet and high schools at 60 square feet per person. Bad news for teachers for sure, but hospitals are not far behind in social density, so I am right there, too. Home is the least dense environment at 734 square feet per person.
So, if you are sick, stay home. Take a sick day or two. Do not infect your co-workers or fellow students. Rest and get plenty of fluids and Tylenol. Take care of yourself. Of course, if you are really sick, come see us in the ER. And get your flu shot! It is still not too late.