Panicked stress may be killing more people than the disease itself
SEATTLE, ATLANTA, HONG KONG––Amid escalating global panic over the worldwide rapid spread of the recently identified coronavirus COVID-19, a person not familiar with ProMED–mail might expect the most panic-stricken person of all to be ProMED–mail deputy editor Marjorie P. Pollack, M.D.
ProMED-mail is the moderated online information exchange serving the 75,000 members worldwide of the Program for Monitoring Emerging Diseases, hosted by the International Society for Infectious Diseases at https://www.promedmail.org.
As deputy editor, Pollack has probably seen more data pertaining to COVID-19 than anyone else, living or dead.
Not freaking out
Pollack, who on December 30, 2019 first made the then unknown disease eventually named COVID-19 known to the world, certainly is not taking it lightly. But neither is Pollack freaking out.
The same may be said of the hundreds of epidemiologists, virologists, other public health professionals, and journalists whose research informs the notably calm, factual ProMED-mail coverage under Pollack’s direction, enabling Pollack to issue at least two update summaries a day, seven days a week, since January 3, 2020.
On the job for ProMED-mail since 1998, Pollack has seen international disease scares come and go. Among them were the Nipah virus scare of 1999, the SARS scare of 2003, the H5N1 scare of 2004, the swine flu scare of 2009, when swine flu actually killed 12,000 of 61 million U.S. victims, the MERS-COV scare of 2013, and multiple panics over outbreaks of Ebolavirus––which, with a death rate running close to 80%, might be the most panic-worthy disease still at large and still killing thousands of people per year.
“Seek and ye shall find”
Pollack has also tracked disease outbreaks of significance that the public barely noticed. During the 2018-2019 influenza season, for instance, when the most widely distributed flu vaccine was only 10% effective, an average of 94 Americans per day died from flu, but that toll––six times the current cumulative death toll from U.S. cases of COVID-19––had practically no visible effect on public policy, how people led their day-to-day lives, and/or the stock market.
Recalling her past experience at monitoring epidemics and pandemics, Pollack on February 28, 2020 briefly editorialized that “The identification of [COVID-19] cases without identifiable epidemiologic links strongly suggests that we are moving into the stage of ‘seek and ye shall find.’
“Changing the case definition to eliminate the requirement for known contact with people in, or recently from, known areas of viral circulation,” as has occurred since testing to detect COVID-19 has become more commonplace, “will probably result in an ever growing number of confirmed cases identified,” Pollack predicted.
“Don’t look and it ain’t there”
“That prior case definition worked well in the early stages of this epidemic,” Pollack suggested, “but more recently [works] against identifying community transmission outside of known case contacts, leading to a bias for ‘don’t look and it ain’t there’ results. The silent transmission into these communities speaks for the likelihood of more mild clinical presentations and subclinical infections breaking the directly identifiable epidemiologic links.”
Translation: as Ottawa Public Health associate medical officer Monir Tahir, M.D. advised via ProMED-mail back on January 16, 2020, “With most infectious disease what we see is just the tip of the iceberg. Almost certainly there is wider spread beyond the cases that we actually detect. This is especially so when an infection has a spectrum of illness: we are more likely to detect the severe cases and miss those that are less severe.”
Tahir advanced a hypothesis, since confirmed, that COVID-19 was “already wider spread among the population” of the city of Wuhan, where it was first discovered, and of China and the world, than anyone imagined early in the outbreak.
Unidentified animal host
Back then, in the last days of December 2019 and first two weeks of 2020, the only people tested for COVID-19 were those who had both severe symptoms and known exposure to the Huanan Seafood Wholesale Market in Wuhan.
Selling live animals of a wide variety of species, the Huanan Seafood Wholesale Market is believed to have been where COVID-19 crossed over from an as yet unidentified animal host, probably a bat, to humans, likely through an intermediary host such as a pangolin.
Commented Pollack a day after Tahir posted, “There may already be significant ongoing transmission of this novel coronavirus,” then still not yet formally named COVID-19, “but fortunately the overwhelming majority of cases are presenting with relatively mild and self-limited symptoms of fever, sore throat, and cough, a common presentation during the high season for febrile respiratory illnesses. Many people do not seek medical attention, or when seen are given the diagnosis of viral syndrome,” meaning a common cold or mild flu.
11 million exposed before anyone noticed
What all of that meant, in practical terms, is that COVID-19 appears to pass so easily from person to person that perhaps upward of 11 million people––the entire population of Wuhan––had already been exposed for two months, from the first identified cases in early November 2019 until January 2020, before there were enough severe cases (a few dozen) for anyone to even begin looking into it.
Further, thousands of potentially exposed Wuhan residents had already traveled throughout China. Many had traveled to other cities around the world. If they fell ill with common cold or flu symptoms, this is what they assumed they had, and no one else imagined those were symptoms of anything else.
Even after the existence of COVID-19 became known, most people who were tested after displaying possible symptoms turned out to have something else.
Most suspected cases are something else
Observed Pollack on January 6, 2020, “of 21 cases [investigated in Hong Kong] with fever and respiratory illness and history of travel to or from Wuhan in the past 14 days, 16 had confirmed respiratory viral illnesses” of nine types other than COVID-19. This was “an expected mixture,” Pollack explained, “of respiratory viruses seen at this time of year.”
Both then, and to this day in mid-March 2020, the overwhelming majority of confirmed COVID-19 cases are in senior citizens with pre-existing serious health conditions, the same population who are at by far the greatest risk from familiar respiratory viruses.
Low death rate
Most others who present possible COVID-19 symptoms turn out to have much better known and much less feared illnesses, which rarely kill anyone except those with severely impaired immune systems, such as HIV patients, or with pre-existing lung diseases.
Even among cases severe enough to present symptoms and be confirmed by testing, COVID-19 has an extremely low death rate: less than half the death rate from common influenzas in the U.S. during the 2018-2019 flu season, and less than 10% of the death rate from common pneumonia cases severe enough to require hospital care.
What about dogs?
Paradoxically, considering the often volatile emotional attachment people tend to have to pets, international media coverage of the first known transmission of COVID-19 to a dog has so far been much more level-headed than most coverage of the human cases.
Explained Wen Simin, Yang Ge, and Flynn Murphy of the Beijing-based business & financial news portal Caixin on March 5, 2020, “A pet Pomeranian who repeatedly tested ‘weak positive’ for the virus that causes COVID-19 most likely got it from its owner, raising questions about whether the animal could serve as a host and infect others, or whether the traces found in its body were even viable.
“Experts who discussed the case in Hong Kong agreed the virus came from the dog’s owner, who tested positive for COVID-19, but cautioned against jumping to other conclusions,” the Caixin journalists continued. “The Hong Kong Agriculture, Fisheries & Conservation Department, which first announced the case, also stressed that there is still no evidence to show pets can transmit the virus, adding that owners need not worry too much and should certainly not consider abandoning their animals.”
“The real driver of the outbreak is humans”
University of Nottingham professor of molecular virology Jonathan Ball “stressed the importance of differentiating between a real infection and simply the presence of the virus, and emphasized the need not to overreact,” summarized the Caixin reporters.
“I still think it’s questionable how relevant it is to the human outbreak,” said Ball, “as most of the global outbreak has been driven by human-to-human transmission. We need to find out more, but we don’t need to panic––I doubt it could spread to another dog or a human because of the low levels of the virus. The real driver of the outbreak is humans.”
Within China, panic over COVID-19 had already reportedly led to some village officials ordering pet keepers to kill or quarantine their animals, and some tabloid media published probably faked photographs of pets who had purportedly been tossed from tall buildings.
But the World Small Animals Veterinary Association pointed out as early as February 17, 2020 that, “Currently there is no evidence that pets or other domestic animals can be infected with this new coronavirus. Additionally, there is currently no evidence that pets or other domestic animals might be a source of infection to people.”
Cats, pigs, ferrets, monkeys?
A study entitled “Receptor recognition by novel coronavirus from Wuhan: an analysis based on decade-long structural studies of SARS,” published by the Journal of Virology, hypothesized from research done in response to the SARS outbreak of 17 years earlier that cats, pigs, ferrets, and non-human primates might be susceptible enough to COVID-19 to serve as laboratory animal models in the quest to develop a vaccine.
However, since neither cats, pigs, ferrets, nor non-human primates are known to have ever caught COVID-19 under normal circumstances, exceptional efforts would likely be required to infect any of them in a laboratory.
Peking University Health Science Center School of Basic Medical Sciences microbiologist Wei Ji meanwhile “looked for a sign that COVID-19 had adapted to any specific animal host,” reported Ewen Callaway and David Cyranoski for the journal Nature.
Not found in snakes & birds, either
This work was done chiefly to try to more specifically identify the source of COVID-19. Though COVID-19 is believed to have originated in bats, who carry a wide variety of coronaviruses, which of the more than 100 bat species found in China is the specific host is presently anyone’s guess. COVID-19 then may have infected humans with infected pangolins as the suspected intermediary carrier––but not necessarily, as the transmission may have been directly from bat to human, or have come through another intermediary host.
The Wei Ji team investigated potential COVID-19 hosts including hedgehogs, pangolins, bats, chickens, humans, and snakes. They found a hint that the COVID-19 molecular structure was adapted to infect two venomous snake species, Bungarus multicinctus (the many-banded krait) and Naja atra (the Chinese cobra).
Either might turn up in a Chinese live wildlife market, albeit as rare contraband, but no reptiles are actually known to carry coronaviruses.
“There is no consistent evidence of coronaviruses in hosts other than mammals and Aves (birds),” responded University of São Paulo virologist Paulo Eduardo Brandão, “who is investigating whether coronaviruses can infect snakes at all,” the Nature writers noted.
Expanded primate research likely
International Primate Protection League founder Shirley McGreal, exposing misuse and mistreatment of nonhuman primates in biomedical research since 1973, has expressed well-founded concern that COVID-19 will provide a pretext for expanding the use of monkeys and apes in studies likely to cause considerable suffering, with small likelihood of yielding any useful knowledge that could not be derived from clinical studies of the thousands of human victims––or, more specifically, study of tissue, sputum, and effluents.
At particular risk may be 63 chimpanzees housed at the Alamogordo Primate Facility in New Mexico, whom National Institutes of Health director Francis Collins announced in October 2019 would not be retired to Chimp Haven, in Florida, as previously promised, because of their advanced ages and frail health.
These are exactly the traits that might incline COVID-19 researchers to try to use them as models.
Chimpanzees, an African species, likely have had no evolutionary exposure to COVID-19, and therefore probably have no more resistance to it than people do.
The 100,000-or-so macaques in federally funded laboratories, however, may be another story. As members of several semi-arboreal Asian species, macaques spend a lot of time in trees, much closer to bats than most humans. Some macaques eat bats, if they catch them. Thus macaques might long since have evolved resistance to COVID-19 rendering them useless as models for the human infection.
But only wasting a lot of time, money, and macaque lives is likely to find out.
“Don’t get around much any more”
Meanwhile, the ANIMALS 24-7 team are not traveling much these days, due to limited resources, but if we were, first of all, we do not take the risk of contracting any zoonotic disease any more lightly than does ProMED.
Reporting from the front lines of many zoonotic disease outbreaks around the world over the decades, we have experienced some really bad bouts with zoonoses, notably advanced Lyme disease, West Nile virus, and a bad reaction to yellow fever vaccine.
With that much said, we would have no anxiety associated with COVID-19 about personally inspecting the live markets of anywhere in China, some of which we have already seen, with no mask and taking no other precautions except making sure we had our own water bottles.
Why water bottles?
We would carry water bottles filled from a clean source because dehydration is a much greater threat than potentially inhaling COVID-19 or any other easily transmitted virus.
We would not be touching the snakes and turtles, having learned to avoid any risk of salmonella back in childhood.
As regards the cruelty to animals, and we have seen a lot of that in live markets over the years, breakfast would be light and lunch would be postponed.
Disappointment would be acute that while China has made a great show of banning “wildlife” from live markets, the enforcement regulations exempt captive-raised animals of 54 species.
“Fox, mink, raccoon dog (tanuki), deer, ostrich, and many species of bird among others are categorized as livestock rather than wildlife,” pointed out ACTAsia for Animals founder Pe Su on February 27, 2020.
18 local deaths & what they really mean
Meanwhile here at home, in the greater Seattle area, 18 people have died from COVID-19, as of this writing, 17 of them either residents or former residents of the EvergreenHealth care facility in Kirkland, which specializes in providing care to patients with severe underlying health conditions.
ANIMALS 24-7 is informed by colleagues that some companies located 3,000 miles away are sufficiently concerned about this confluence of relatively predictable deaths that “any employee who has been to Seattle or has been in close contact with anyone who has recently been to Seattle is required to work from home for two weeks.”
By way of perspective, the Seattle metropolitan area includes four million people, ourselves among them. In addition, the Seattle-Tacoma airport handles about 60,000 transfer passengers per day, who mostly never leave the airport but are exposed to the other 80,000 passengers who have been outside, as well as to any fellow passengers who may have visited China, Italy, Iran, Japan, or anywhere else with notable numbers of COVID-19 cases.
You are more likely to be murdered
Yet only 104 people have tested positive for COVID-19, even though a shortage of test kits means only the people most likely to test positive are being tested.
The death rate works out to 4.5 per million people, and is likely to rise as more of the most vulnerable part of the human population are exposed: chiefly the frail aged, people already suffering from emphysema, lung cancer, asbestosis, and other severe lung diseases, and people with impaired immune systems, such as HIV victims.
Consider, though, that the U.S. murder rate is 5.0 per million, and in New York City, one of the cities most frightened by COVID-19, the murder rate is 37.5 per million.
How much testing is necessary to catch carriers?
ANIMALS 24-7 is seeing great anxiety that relatively few Americans so far have been tested for COVID-19, after exhibiting initial symptoms also associated with common colds, flus, and even seasonal allergies.
Ideally, everyone who wants to be tested for COVID-19 should be, and perhaps eventually will be, but as regards epidemic risk, that few people are being tested is of small significance.
This is because it is already known, and has been known for two months now, that the vast majority of people who are exposed to COVID-19 either do not develop symptoms at all, and therefore do not shed the coronavirus via sneezing or coughing, or do not develop symptoms serious enough to warrant a medical response.
COVID-19 vs. drunk driving
Compare the situation to drunk driving, which kills 30 Americans per day, amounting to more than 10,000 deaths per year in the U.S. alone.
Because drunk driving can be very dangerous when it occurs, police test about 1.5 million people per year for driving under the influence of alcohol or other intoxicants. About 800,000 of those tested are not allowed to drive themselves home.
But that 1.5 million, about .0004 percent of the total U.S. population, are the portion showing serious enough symptoms of driving while intoxicated for a police officer to stop them.
It is not necessary to test all 222 million U.S. drivers to ensure that drunk driving does not kill significantly more people than it already does, about 10,000 per year now, triple the current global toll from COVID-19, or even to test 1% of all drivers.
Testing those who show symptoms is sufficient.
Why COVID-19 is not the 1918 Spanish flu
“The public is behaving as if this epidemic is the next Spanish flu,” observed Brigham & Women’s Hospital in Boston emergency physician Jeremy Samuel Faust via Harvard Health Blog on March 4, 2020, “which is frankly understandable, given that initial reports have staked COVID-19 mortality at about 2–3 percent, quite similar to the 1918 pandemic that killed tens of millions of people.
“These frightening numbers are unlikely to hold. The true case fatality rate is likely to be far lower than current reports suggest. Even some lower estimates, such as the 1% death rate recently mentioned by the directors of the National Institutes of Health and the Centers for Disease Control & Prevention, likely substantially overstate the case,” Faust explained.
In simplest terms, as more people are tested, including more people whose symptoms are marginal, many more cases will be diagnosed from which the victims recover without lasting effects, and without passing COVID-19 to others.
Fatality rate already rapidly dropping
“We are already seeing this,” Faust reported. “In the early days of the crisis in Wuhan, China, the case fatality rate was more than 4%. As the virus spread to other parts of Hubei province, the number fell to 2%. As it spread through China, the reported case fatality rate dropped further, to 0.2 to 0.4%.”
At that, pointed out Stephen A. Berger, M.D. of the Tel Aviv Medical Center, cofounder of the Global Infectious Diseases & Epidemiology Network, via ProMED on February 28, 2020, “How many infections in China are asymptomatic or sub-clinical? If, for example, only one-in-10 individuals who acquire infection by COVID-19 are sufficiently ill to visit a clinic or hospital, the true case-fatality rate decreases from 3.4% [the rate most widely reported] to 0.34%.”
Agreed Marjorie Pollack, to Partha Bose of the Oliver Wyman Forum, “I suspect we’re going to find that the case fatality rate will be less than 1%. What you see with most new diseases, [is that] your initial picture [is from] the very severe cases that come to the attention of the health sector” first.